25D2179208 CLIA NUMBER - PURE LIGHT PSYCHIATRY

Laboratory Demographics

  • CLIA Code: 25D2179208
  • Facility Name: PURE LIGHT PSYCHIATRY
  • Facility Address: 5600 GOODMAN RD STE B
    OLIVE BRANCH, MS
    ZIP 38654
  • Facility Phone: 662 890-7010
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: STEPHANIE M. DOUGLASS
  • NPI Number: 1932742988
  • Taxonomy: 363LP0808X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 25D2179208
LAB Type Practitioner Other
Facility Name PURE LIGHT PSYCHIATRY
Street 5600 GOODMAN RD STE B
City OLIVE BRANCH
State MS
ZIP 38654
Phone 662 890-7010
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/18/2024
Certificate Expiration Date 2/17/2026
Facility Type Practitioner Other
Lab Director STEPHANIE M. DOUGLASS

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This page was last updated on: 9/29/2025