Provider Demographics
NPI:1427177443
Name:MCCOY, RAVEN (PT)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:MCCOY
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 1:1054 HIGHLAND COVE PL
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1523
Mailing Address - Country:US
Mailing Address - Phone:601-636-6019
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:2475 LAKELAND DR STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9505
Practice Address - Country:US
Practice Address - Phone:601-664-1022
Practice Address - Fax:601-664-1076
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist