Provider Demographics
NPI:1750577805
Name:LIVE OAK PSYCHOLOGICAL ASSOCITAES
Entity type:Organization
Organization Name:LIVE OAK PSYCHOLOGICAL ASSOCITAES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:HALDERMAN
Authorized Official - Last Name:DIETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-352-7398
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:STE 212
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-352-7398
Mailing Address - Fax:601-352-0442
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:STE 212
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-352-7398
Practice Address - Fax:601-352-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty