Healthcare Provider Details

I. General information

NPI: 1801192307
Provider Name (Legal Business Name): PROFESSIONAL REHAB ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 A HARRISON AVE
MCCOMB MS
39648
US

IV. Provider business mailing address

1301 A HARRISON AVE
MCCOMB MS
39648
US

V. Phone/Fax

Practice location:
  • Phone: 601-250-5455
  • Fax: 601-250-5453
Mailing address:
  • Phone: 601-250-5455
  • Fax: 601-250-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. BRAD WILSON
Title or Position: PRESIDENT
Credential: DPT, ATC
Phone: 601-250-5455