Healthcare Provider Details

I. General information

NPI: 1891915922
Provider Name (Legal Business Name): MANDY WILLIAMS SMITH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W NORTH ST
POPLARVILLE MS
39470-2203
US

IV. Provider business mailing address

PO BOX 8419
BILOXI MS
39535-8087
US

V. Phone/Fax

Practice location:
  • Phone: 601-795-2130
  • Fax: 601-795-2164
Mailing address:
  • Phone: 228-388-5714
  • Fax: 228-388-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4141
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: