Provider Demographics
NPI:1518747567
Name:MSU BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:MSU BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-325-0621
Mailing Address - Street 1:PO BOX 6124
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-6124
Mailing Address - Country:US
Mailing Address - Phone:662-325-0621
Mailing Address - Fax:662-325-0895
Practice Address - Street 1:223 FAMOUS MAROON BAND STREET
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762
Practice Address - Country:US
Practice Address - Phone:662-325-0621
Practice Address - Fax:662-325-0895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-05
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty