Healthcare Provider Details

I. General information

NPI: 1538051149
Provider Name (Legal Business Name): REBECCA PONTHIEUX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 PUSHAPATAPA RD
TYLERTOWN MS
39667-7016
US

IV. Provider business mailing address

116 E CANAL ST
PICAYUNE MS
39466-4506
US

V. Phone/Fax

Practice location:
  • Phone: 769-926-1137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1569
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: