Basic Information
| Provider Information | |||||||||
| NPI: | 1598954703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLWOOD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018337317 | ||||||||
| FaxNumber: | 6018350995 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018337317 | ||||||||
| FaxNumber: | 6018350995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA3648 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.