Provider Demographics
NPI:1285291799
Name:POTTS, DYLAN CHASE (PTA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:CHASE
Last Name:POTTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 RUTH LINNEY RD
Mailing Address - Street 2:
Mailing Address - City:ROARING RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28669-8700
Mailing Address - Country:US
Mailing Address - Phone:336-981-4749
Mailing Address - Fax:
Practice Address - Street 1:13600 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278
Practice Address - Country:US
Practice Address - Phone:704-705-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6909225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant