Provider Demographics
NPI:1205193075
Name:BOX, BRITTANY RACHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:RACHAEL
Last Name:BOX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 PALESTINE RD
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-9190
Mailing Address - Country:US
Mailing Address - Phone:662-419-6964
Mailing Address - Fax:
Practice Address - Street 1:2844 TRACELAND DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4200
Practice Address - Country:US
Practice Address - Phone:662-680-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4241225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS314000000XOtherBLUE CROSS BLUE SHIELD