1134962525 NPI number — BEACON BEHAVIORAL OF MISSISSIPPI, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134962525 NPI number — BEACON BEHAVIORAL OF MISSISSIPPI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON BEHAVIORAL OF MISSISSIPPI, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134962525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37230-6600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-420-5810
Provider Business Mailing Address Fax Number:
601-420-5811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3531 LAKELAND DR STE 1060
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-8016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-420-5810
Provider Business Practice Location Address Fax Number:
601-420-5811
Provider Enumeration Date:
06/14/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GLAVESKAS
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
443-962-3945

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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