Provider Demographics
NPI:1891915922
Name:SMITH, MANDY WILLIAMS (PT)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:WILLIAMS
Last Name:SMITH
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:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:411 W NORTH ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-2203
Practice Address - Country:US
Practice Address - Phone:601-795-2130
Practice Address - Fax:601-795-2164
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS090-15077Medicaid
MS1033218524OtherGROUP NPI
MSC02726Medicare PIN