Provider Demographics
NPI:1366939100
Name:SULTON, TISHOUNNA KNOX (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TISHOUNNA
Middle Name:KNOX
Last Name:SULTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 MEAGAN DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-5676
Mailing Address - Country:US
Mailing Address - Phone:769-216-0815
Mailing Address - Fax:601-510-9049
Practice Address - Street 1:2260 MEAGAN DR
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-5676
Practice Address - Country:US
Practice Address - Phone:769-216-0815
Practice Address - Fax:601-510-9049
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC64491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty