Basic Information
Provider Information | |||||||||
NPI: | 1457696361 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLACK MOUNTAIN PHYSICAL THERAPY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | PO BOX 392573 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152519573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7245845739 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 997 W OLD US 70 HWY | ||||||||
Address2: |   | ||||||||
City: | BLACK MOUNTAIN | ||||||||
State: | NC | ||||||||
PostalCode: | 28711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286696896 | ||||||||
FaxNumber: | 8286696897 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2012 | ||||||||
LastUpdateDate: | 08/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | METAL-CONFER | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR. CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7244482733 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 08/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.