Provider Demographics
NPI:1760924583
Name:BEASLEY, JAMES DARREN (PTA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DARREN
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9027 S ROCKY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:36320-4406
Mailing Address - Country:US
Mailing Address - Phone:334-685-2673
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36360
Practice Address - Country:US
Practice Address - Phone:334-685-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26823225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant