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General NPI Number Information
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NPI Number | 1104743145
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Entity Type | Individual
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Provider Name | MILLIE GRACE MASK PT
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Gender | Female
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Dates
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Enumeration Date | 07/01/2026
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Last Update Date | 07/01/2026
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Provider Practice Location Address
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Address Line | 2015 HIGHPOINTE DR
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City | BRANDON
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State | MS
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Zip | 39042-3169
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Country | US
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Telephone | 601-724-8886
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Fax | 601-724-8887
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Provider Business Mailing Address
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Address Line | 25025 HIGHWAY 15
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City | UNION
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State | MS
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Zip | 39365-8577
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Country | US
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Telephone | 769-222-1053
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Fax | 769-222-1167
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT8157
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License Number State | MS
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