Basic Information
| Provider Information | |||||||||
| NPI: | 1891915922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | WILLIAMS | ||||||||
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| Credential: | PT | ||||||||
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| 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: | 04/30/2007 | ||||||||
| LastUpdateDate: | 11/21/2008 | ||||||||
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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 | PT4141 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 090-15077 | 05 | MS | MEDICAID | 1033218524 | 01 | MS | GROUP NPI | OTHER |