Provider Demographics
NPI:1407205073
Name:HAMILTON, MANDI (PTA)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9385
Mailing Address - Country:US
Mailing Address - Phone:803-900-4020
Mailing Address - Fax:803-753-9362
Practice Address - Street 1:2 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9385
Practice Address - Country:US
Practice Address - Phone:803-900-4020
Practice Address - Fax:803-753-9362
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2438225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant