=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649356478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINNY REBECCA DEHART PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5545 PINE LANE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39211-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-957-2976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5545 PINE LANE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39211-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-957-2976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT3321
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------