Provider Demographics
NPI:1487950564
Name:SOUTHERN BEHAVIORAL MEDICINE ASSOCIATES PLLC
Entity type:Organization
Organization Name:SOUTHERN BEHAVIORAL MEDICINE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DATZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-255-1618
Mailing Address - Street 1:PO BOX 18799
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8799
Mailing Address - Country:US
Mailing Address - Phone:601-255-1618
Mailing Address - Fax:601-255-1619
Practice Address - Street 1:1 COMMERCE DR
Practice Address - Street 2:STE 106
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1499
Practice Address - Country:US
Practice Address - Phone:601-255-1618
Practice Address - Fax:601-255-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty