Provider Demographics
NPI:1841766052
Name:BUSH, RHONDA MICHELLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:RHONDA
Middle Name:MICHELLE
Last Name:BUSH
Suffix:
Gender:F
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:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0457
Mailing Address - Country:US
Mailing Address - Phone:601-587-2563
Mailing Address - Fax:
Practice Address - Street 1:217 METHODIST BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1338
Practice Address - Country:US
Practice Address - Phone:601-329-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA2817225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant