Healthcare Provider Details

I. General information

NPI: 1801370929
Provider Name (Legal Business Name): SOUTHERN PHYSICAL THERAPY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 HIGHWAY 11 N STE C
PICAYUNE MS
39466-2070
US

IV. Provider business mailing address

1620 HIGHWAY 11 N STE C
PICAYUNE MS
39466-2070
US

V. Phone/Fax

Practice location:
  • Phone: 769-242-2626
  • Fax: 769-242-2685
Mailing address:
  • Phone: 769-242-2626
  • Fax: 769-242-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM LOUIS ROBIN
Title or Position: PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 769-242-2626