Healthcare Provider Details

I. General information

NPI: 1720282247
Provider Name (Legal Business Name): PROFESSIONAL PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N HAYDEN ST
BELZONI MS
39038-3639
US

IV. Provider business mailing address

401 N HAYDEN ST
BELZONI MS
39038-3639
US

V. Phone/Fax

Practice location:
  • Phone: 662-247-4446
  • Fax: 662-247-2772
Mailing address:
  • Phone: 662-247-4446
  • Fax: 662-247-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3777
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1324
License Number StateMS

VIII. Authorized Official

Name: DANA CARTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-247-4446