Basic Information
| Provider Information | |||||||||
| NPI: | 1669712790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAFFERTY | ||||||||
| FirstName: | TERRENCE | ||||||||
| MiddleName: | CALEB | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 N WALMART DR STE F | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393396898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627791096 | ||||||||
| FaxNumber: | 6627793949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2013 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5197 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.