Provider Demographics
NPI:1891136818
Name:CHILDREN'S PSYCHIATRIC CLINIC
Entity type:Organization
Organization Name:CHILDREN'S PSYCHIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILKAITIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-829-4170
Mailing Address - Street 1:3531 LAKELAND DR STE 1052
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8016
Mailing Address - Country:US
Mailing Address - Phone:601-982-8531
Mailing Address - Fax:
Practice Address - Street 1:3531 LAKELAND DR STE 1052
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8016
Practice Address - Country:US
Practice Address - Phone:601-829-4170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03932074Medicaid