Healthcare Provider Details

I. General information

NPI: 1790585610
Provider Name (Legal Business Name): 2083 THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LAKESIDE DR
PHILADELPHIA MS
39350-6504
US

IV. Provider business mailing address

PO BOX D
FOREST MS
39074-0558
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax:
Mailing address:
  • Phone: 601-469-4151
  • Fax: 601-469-9927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH MCNULTY
Title or Position: CEO
Credential:
Phone: 601-469-4151