Provider Demographics
NPI:1689808701
Name:BEAMON, VALENCIA REYNOLDS (RPT)
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:REYNOLDS
Last Name:BEAMON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:MS
Mailing Address - Zip Code:39045-9005
Mailing Address - Country:US
Mailing Address - Phone:662-571-4889
Mailing Address - Fax:662-468-0622
Practice Address - Street 1:1834 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:MS
Practice Address - Zip Code:39045-9005
Practice Address - Country:US
Practice Address - Phone:662-571-4889
Practice Address - Fax:662-468-0622
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014160Medicaid
MS09014160Medicaid