Provider Demographics
NPI:1598327181
Name:ROBERTS, RAYCHAL REED (PR, DPT)
Entity Type:Individual
Prefix:MRS
First Name:RAYCHAL
Middle Name:REED
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PR, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206B OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-4445
Mailing Address - Fax:662-534-9449
Practice Address - Street 1:3437 TUPELO CMNS STE 102
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9791
Practice Address - Country:US
Practice Address - Phone:662-680-3200
Practice Address - Fax:662-680-5090
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist