Provider Demographics
NPI:1760508865
Name:SHIRES, CYNTHIA L (PT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:SHIRES
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 1:4820 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9666
Mailing Address - Country:US
Mailing Address - Phone:601-922-7022
Mailing Address - Fax:
Practice Address - Street 1:4820 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9666
Practice Address - Country:US
Practice Address - Phone:601-922-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist