Basic Information
| Provider Information | |||||||||
| NPI: | 1609980838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESDUNE-MONT | ||||||||
| FirstName: | CHERYLANN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DESDUNE | ||||||||
| OtherFirstName: | CHERYLANN | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 N MAIN ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645285700 | ||||||||
| FaxNumber: | 8645285701 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | STE C250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540952 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5316 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TH1727 | 05 | SC | MEDICAID |