Healthcare Provider Details

I. General information

NPI: 1992517825
Provider Name (Legal Business Name): TATYANNA LA'SHEA HOLLINS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 FOREST DR STE B101
COLUMBIA SC
29204-4146
US

IV. Provider business mailing address

715 CRANE CHURCH RD
COLUMBIA SC
29203-1415
US

V. Phone/Fax

Practice location:
  • Phone: 803-764-2363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6804
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: