Provider Demographics
NPI:1821434259
Name:ADDISON, TRISHA
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:ADDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SOUTH FRONTAGE ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180
Mailing Address - Country:US
Mailing Address - Phone:601-456-0159
Mailing Address - Fax:
Practice Address - Street 1:2222 SOUTH FRONTAGE ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-456-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist