=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871528364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERRILL HOPE BACKSTROM PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 07/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 MAIN ST
-----------------------------------------------------
City | LEAKESVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39451-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-394-4545
-----------------------------------------------------
Fax | 601-394-4546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8419
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39535-8087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-388-5714
-----------------------------------------------------
Fax | 228-388-0017
-----------------------------------------------------
=====================================================
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 | PT1051
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------