Healthcare Provider Details

I. General information

NPI: 1689614075
Provider Name (Legal Business Name): PHYSICAL THERAPY OF TELLICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8805 NEW HIGHWAY 68 UNIT 1
TELLICO PLAINS TN
37385-5347
US

IV. Provider business mailing address

PO BOX 483
TELLICO PLAINS TN
37385-0483
US

V. Phone/Fax

Practice location:
  • Phone: 423-253-6522
  • Fax: 423-253-3664
Mailing address:
  • Phone: 423-253-6522
  • Fax: 423-253-3664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000004777
License Number StateTN

VIII. Authorized Official

Name: MRS. NICOLE MARIE CRESSWELL
Title or Position: OWNER
Credential: MSPT
Phone: 423-253-6522