Healthcare Provider Details

I. General information

NPI: 1760672448
Provider Name (Legal Business Name): SUSAN CAPPELLI PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2007
Last Update Date: 07/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7597 ATTALA ROAD 5216
KOSCIUSKO MS
39090-6401
US

IV. Provider business mailing address

7597 ATTALA ROAD 5216
KOSCIUSKO MS
39090-6401
US

V. Phone/Fax

Practice location:
  • Phone: 601-416-5715
  • Fax:
Mailing address:
  • Phone: 601-416-5715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberPT3473
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPT3473
License Number StateMS

VIII. Authorized Official

Name: SUSAN CAPPELLI
Title or Position: MANAGING MEMBER
Credential: MPT
Phone: 601-416-5715