Provider Demographics
NPI:1124616354
Name:DELTA LIFE THERAPEUTIC SOLUTIONS PLLC
Entity type:Organization
Organization Name:DELTA LIFE THERAPEUTIC SOLUTIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMELJA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-458-0408
Mailing Address - Street 1:705 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:ITTA BENA
Mailing Address - State:MS
Mailing Address - Zip Code:38941-2603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 1/2 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:ITTA BENA
Practice Address - State:MS
Practice Address - Zip Code:38941
Practice Address - Country:US
Practice Address - Phone:662-458-0408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health