Healthcare Provider Details

I. General information

NPI: 1326098252
Provider Name (Legal Business Name): RAYMOND A BELISLE MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5132 BEATLINE RD SUITE D
LONG BEACH MS
39560-3869
US

IV. Provider business mailing address

PO BOX 8419
BILOXI MS
39535-8087
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-8429
  • Fax: 228-575-8891
Mailing address:
  • Phone: 228-388-5714
  • Fax: 228-388-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number06525R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4978
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: