Provider Demographics
NPI:1912130063
Name:HARRELL, RYAN H (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:H
Last Name:HARRELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 FLORA GENE AVE W STE D
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-5010
Mailing Address - Country:US
Mailing Address - Phone:601-523-1994
Mailing Address - Fax:601-523-1995
Practice Address - Street 1:321 FLORA GENE AVE W STE D
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-5010
Practice Address - Country:US
Practice Address - Phone:601-523-1994
Practice Address - Fax:601-523-1995
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7838791Medicaid