Provider Demographics
NPI:1548961501
Name:COTTON, CARL RANDY (PHD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:RANDY
Last Name:COTTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:RANDOLPH
Other - Last Name:COTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:208 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2310
Mailing Address - Country:US
Mailing Address - Phone:601-906-2920
Mailing Address - Fax:
Practice Address - Street 1:208 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2310
Practice Address - Country:US
Practice Address - Phone:601-213-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33-517103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical