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General NPI Number Information
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NPI Number | 1497552079
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Entity Type | Organization
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Legal Business Name | METAMORPHOSIS REHABILITATION, LLC
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Dates
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Enumeration Date | 02/28/2025
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 5170 SUNNYVALE DR
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City | JACKSON
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State | MS
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Zip | 39211-4845
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Country | US
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Telephone | 909-570-1198
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Fax |
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Provider Business Mailing Address
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Address Line | 5170 SUNNYVALE DR
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City | JACKSON
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State | MS
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Zip | 39211-4845
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Country | US
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Telephone | 909-570-1198
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Fax |
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Authorized Official
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Title or Position | OWNER/SENIOR CLINICIAN
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Name | DR. MYNA LAQUISHA BURKS
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Credential | PH. D.
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Telephone | 909-570-1198
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QR0208X
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Taxonomy Name | Mobile Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number |
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License Number State |
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