Basic Information
| Provider Information | |||||||||
| NPI: | 1801429774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTENBERRY | ||||||||
| FirstName: | HAYDEN | ||||||||
| MiddleName: | BROOKS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 W BEACON ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393503229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W GOVERNMENT ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390423196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015917535 | ||||||||
| FaxNumber: | 6015917540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6670 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.