Provider Demographics
NPI:1699788109
Name:ADVANCED THERAPY, PLLC
Entity type:Organization
Organization Name:ADVANCED THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:919-846-9668
Mailing Address - Street 1:8300 FALLS OF NEUSE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-846-9668
Mailing Address - Fax:919-846-9663
Practice Address - Street 1:8300 FALLS OF NEUSE RD
Practice Address - Street 2:STE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-846-9668
Practice Address - Fax:919-846-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211368Medicaid
NC7211368Medicaid