NPIMap

Organization Active NPI

Desoto Family Wellness Center, LLC

  • Multi-Specialty Clinic/Center
  • Southaven, MS
National Provider Identifier
1376143024
Registry record updated Sep 18, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
DESOTO FAMILY WELLNESS CENTER, LLC
Practice address
3495 Cobblestone Blvd S
Southaven, MS 38672-7075
Phone
(662) 892-2885
Fax
(662) 892-2889
NPI assigned
Oct 30, 2020
Last updated
Sep 18, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 18, 2023

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

Authorized official

Name
Amy Lynn Ollar
Title
Office Manager
Phone
(662) 892-2885

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 101YP2500X
Counseling PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC1900X
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Multi-Specialty Clinic/Center 261QM1300X Primary
Family Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363LF0000X
Primary Care Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363LP2300X

Addresses

Primary practice location

3495 Cobblestone Blvd S
Southaven, MS 38672-7075

Mailing address

3495 Cobblestone Blvd S
Southaven, MS 38672-7075
Phone (662) 892-2885

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1604016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694995200000",
    "number": "1376143024",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3495 COBBLESTONE BLVD S",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386727075",
            "telephone_number": "662-892-2885",
            "fax_number": "662-892-2889"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3495 COBBLESTONE BLVD S",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386727075",
            "telephone_number": "662-892-2885",
            "fax_number": "662-892-2889"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DESOTO FAMILY WELLNESS CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-30",
        "last_updated": "2023-09-18",
        "certification_date": "2023-09-18",
        "status": "A",
        "authorized_official_last_name": "OLLAR",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "662-892-2885"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "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": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Southaven, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 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.