Healthcare Provider Details

I. General information

NPI: 1497718449
Provider Name (Legal Business Name): TINA D MCNEAL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 VETERANS MEMORIAL DR
KOSCIUSKO MS
39090-3849
US

IV. Provider business mailing address

105 SUMMIT GRV
BRANDON MS
39047-7384
US

V. Phone/Fax

Practice location:
  • Phone: 769-777-4400
  • Fax: 769-777-4401
Mailing address:
  • Phone: 601-906-9052
  • Fax: 601-906-9052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3932
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: