Healthcare Provider Details

I. General information

NPI: 1497552079
Provider Name (Legal Business Name): METAMORPHOSIS REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 SUNNYVALE DR
JACKSON MS
39211-4845
US

IV. Provider business mailing address

5170 SUNNYVALE DR
JACKSON MS
39211-4845
US

V. Phone/Fax

Practice location:
  • Phone: 909-570-1198
  • Fax:
Mailing address:
  • Phone: 909-570-1198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MYNA LAQUISHA BURKS
Title or Position: OWNER/SENIOR CLINICIAN
Credential: PH. D.
Phone: 909-570-1198