Provider Demographics
NPI:1083113120
Name:HALLORAN, THOMAS M (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:HALLORAN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 PARK RD APT 357
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3880
Mailing Address - Country:US
Mailing Address - Phone:704-962-0197
Mailing Address - Fax:
Practice Address - Street 1:8918 BLAKENEY PROFESSIONAL DR STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6692
Practice Address - Country:US
Practice Address - Phone:704-900-8960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-36372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLAT-3637OtherNCBATE