Provider Demographics
NPI:1164766895
Name:DIMMITT, DANNY DUANE (PTA)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:DUANE
Last Name:DIMMITT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6390 RIVERBIRCH PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-5802
Mailing Address - Country:US
Mailing Address - Phone:573-881-4606
Mailing Address - Fax:
Practice Address - Street 1:6390 RIVERBIRCH PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-5802
Practice Address - Country:US
Practice Address - Phone:573-881-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005950225200000X
NMA-0816225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant