Basic Information
| Provider Information | |||||||||
| NPI: | 1841766052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | RHONDA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396540457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015872563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 217 METHODIST BLVD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013292233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2018 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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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 | PTA2817 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.