Provider Demographics
NPI:1124367107
Name:TOLLEY, DUSTIN (PT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:TOLLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MIDLAND PKWY
Mailing Address - Street 2:APT 811
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 STOCKDALE ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7125
Practice Address - Country:US
Practice Address - Phone:843-375-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist