Basic Information
| Provider Information | |||||||||
| NPI: | 1811441843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | ALICIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | DOROTHY | ||||||||
| OtherMiddleName: | ALICIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1004 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433109690 | ||||||||
| FaxNumber: | 8003179690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433109690 | ||||||||
| FaxNumber: | 8003179690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2016 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6283 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6283 | 01 | SC | PROFESSIONAL LICENSE | OTHER |