Provider Demographics
NPI:1053929323
Name:CARTER, LILLIAN ROSE
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:ROSE
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LILLY
Other - Middle Name:ROSE
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:118 COPPER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6948
Mailing Address - Country:US
Mailing Address - Phone:940-300-7288
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-53232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry