Provider Demographics
NPI:1407609076
Name:CREDEUR, MINDY KAYE (PTA)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:KAYE
Last Name:CREDEUR
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 56
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-0056
Mailing Address - Country:US
Mailing Address - Phone:662-714-3122
Mailing Address - Fax:662-714-3124
Practice Address - Street 1:1810 W CERVANTES ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-0001
Practice Address - Country:US
Practice Address - Phone:662-714-3122
Practice Address - Fax:850-782-0058
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA8645225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant