Provider Demographics
NPI:1356478606
Name:BROWN, CECELIA ANNITA (PT)
Entity Type:Individual
Prefix:
First Name:CECELIA
Middle Name:ANNITA
Last Name:BROWN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 AIRWAYS BLVD
Mailing Address - Street 2:BLDG A, STE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4113
Mailing Address - Country:US
Mailing Address - Phone:662-536-4096
Mailing Address - Fax:662-536-4099
Practice Address - Street 1:7900 AIRWAYS BLVD
Practice Address - Street 2:BLDG A, STE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:662-536-4096
Practice Address - Fax:662-536-4099
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4256225100000X
TNPT7658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0183838OtherBLUE CROSS PROVIDER NUMBE
TN446538Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MS256594Medicare Oscar/Certification