Healthcare Provider Details

I. General information

NPI: 1871023176
Provider Name (Legal Business Name): KECIA MICHELLE YELVERTON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OLD RIVER PL STE E
JACKSON MS
39202-3435
US

IV. Provider business mailing address

199 N BROOKMOORE DR
COLUMBUS MS
39705-2024
US

V. Phone/Fax

Practice location:
  • Phone: 601-292-6024
  • Fax: 601-292-6025
Mailing address:
  • Phone: 662-327-6705
  • Fax: 662-327-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT825
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: