Provider Demographics
NPI:1215316708
Name:ELLIOTT, DYLAN BUCKLEY (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:BUCKLEY
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 MASON MILL RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4008
Mailing Address - Country:US
Mailing Address - Phone:904-477-8496
Mailing Address - Fax:
Practice Address - Street 1:150 ATHENS HWY STE 500
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4968
Practice Address - Country:US
Practice Address - Phone:770-554-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist