Provider Demographics
NPI:1972859312
Name:ROY, CHRISTOPHER RICHARD (PTA)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:RICHARD
Last Name:ROY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 VILLAGE CV
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-9498
Mailing Address - Country:US
Mailing Address - Phone:601-622-3560
Mailing Address - Fax:
Practice Address - Street 1:210 VILLAGE CV
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9498
Practice Address - Country:US
Practice Address - Phone:601-622-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42621225200000X
MS4271225200000X
TX2088128225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL42621OtherALABAMA STATE BOARD
MS4271OtherMISSISSIPPI STATE BOARD
TX2088128OtherTEXAS STATE BOARD