Provider Demographics
NPI:1043465040
Name:PSYCAMORE, LLC
Entity type:Organization
Organization Name:PSYCAMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTE-MADAKASIRA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMFT
Authorized Official - Phone:601-939-5993
Mailing Address - Street 1:2540 FLOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9362
Mailing Address - Country:US
Mailing Address - Phone:601-939-5993
Mailing Address - Fax:601-939-5935
Practice Address - Street 1:7165 GETWELL RD
Practice Address - Street 2:BUILDING 3, SUITE 1 & 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9659
Practice Address - Country:US
Practice Address - Phone:800-779-2448
Practice Address - Fax:601-993-5935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)