Provider Demographics
NPI:1962618223
Name:UNIVERSITY OF MISSISSIPPI
Entity type:Organization
Organization Name:UNIVERSITY OF MISSISSIPPI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:662-915-5272
Mailing Address - Street 1:G382 KINARD HALL
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677
Mailing Address - Country:US
Mailing Address - Phone:662-915-7385
Mailing Address - Fax:662-915-1396
Practice Address - Street 1:G382 KINARD HALL
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7385
Practice Address - Fax:662-915-1396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty