Provider Demographics
NPI:1023383569
Name:SOUTHERN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SOUTHERN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:T
Authorized Official - Last Name:TREGRE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:601-336-8287
Mailing Address - Street 1:7 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8552
Mailing Address - Country:US
Mailing Address - Phone:601-336-8287
Mailing Address - Fax:
Practice Address - Street 1:7 WILLOW BEND DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8552
Practice Address - Country:US
Practice Address - Phone:601-336-8287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty