Provider Demographics
NPI:1306242458
Name:MASSEY, PHILIP
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:MASSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2305
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-2305
Mailing Address - Country:US
Mailing Address - Phone:601-272-2202
Mailing Address - Fax:601-292-7998
Practice Address - Street 1:5345 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9421
Practice Address - Country:US
Practice Address - Phone:601-927-0188
Practice Address - Fax:601-292-7998
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM7217104100000X
MSAD07-046M101YA0400X
390200000X
MSC72171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05671221Medicaid