Ignite Clinical Wellness Group

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

IGNITE CLINICAL WELLNESS GROUP

Practice address

5600 Goodman Rd Ste G
Olive Branch, MS 38654-7002

Phone

(662) 985-4101

Fax

(662) 404-7288

NPI assigned

Jul 27, 2023

Last updated

Jul 27, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Derrick O Roach

Title

Chief Operations Officer

Phone

(901) 859-2071

Specialties & licenses 3

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1690416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690416000000",
    "number": "1184305666",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5600 GOODMAN RD STE G",
            "city": "OLIVE BRANCH",
            "state": "MS",
            "postal_code": "386547002",
            "telephone_number": "662-985-4101",
            "fax_number": "662-404-7288"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5600 GOODMAN RD STE G",
            "city": "OLIVE BRANCH",
            "state": "MS",
            "postal_code": "386547002",
            "telephone_number": "662-985-4101",
            "fax_number": "662-404-7288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IGNITE CLINICAL WELLNESS GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-07-27",
        "last_updated": "2023-07-27",
        "certification_date": "2023-07-27",
        "status": "A",
        "authorized_official_last_name": "ROACH",
        "authorized_official_first_name": "DERRICK",
        "authorized_official_middle_name": "O",
        "authorized_official_title_or_position": "CHIEF OPERATIONS OFFICER",
        "authorized_official_telephone_number": "901-859-2071"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Randall T Huling, MD
• Ryan Huling, DPT
• Karmen Hunter, MD
• Ginnifer Poole Hutcheson, DNP, PMHNP-BC
• Tonya H Hylander, FNP
• Melissa J Ince, RPH
• Ayyagari Indiradevi, MD
• Sheryl Ingram
• Inspired Creative Solutions Therapy, LLC
• Integrative Physical Therapy, Inc

• Mental Health Clinic/Center (Including Community Mental Health Center) in Olive Branch, MS
• Providers in Olive Branch, MS by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.