Provider Demographics
NPI:1952286114
Name:FAIRLEY, ALISE R (DPT)
Entity type:Individual
Prefix:
First Name:ALISE
Middle Name:R
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-3317
Mailing Address - Country:US
Mailing Address - Phone:601-746-5101
Mailing Address - Fax:601-746-5102
Practice Address - Street 1:1227 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-3317
Practice Address - Country:US
Practice Address - Phone:601-365-9868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT8047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist