Basic Information
| Provider Information | |||||||||
| NPI: | 1811242589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRELAND | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROGERS | ||||||||
| OtherFirstName: | BETH | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8419 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395358087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 W NORTH ST | ||||||||
| Address2: | |||||||||
| City: | POPLARVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394702203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017952130 | ||||||||
| FaxNumber: | 6017952164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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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 | 225100000X | PT5132 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09015077 | 05 | MS | MEDICAID | 1033218524 | 01 | MS | GROUP NPI | OTHER |