Healthcare Provider Details

I. General information

NPI: 1841861176
Provider Name (Legal Business Name): HOLY CITY PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 SEWEE INDIAN CT
MT PLEASANT SC
29466-8054
US

IV. Provider business mailing address

2103 SEWEE INDIAN CT
MT PLEASANT SC
29466-8054
US

V. Phone/Fax

Practice location:
  • Phone: 423-388-8311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN TOLLEY
Title or Position: OWNER
Credential: DPT
Phone: 423-388-8311