Provider Demographics
NPI:1174267751
Name:DILLON, CODY BLAKE (PTA)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:BLAKE
Last Name:DILLON
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 1:526 WHITE PINES RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24739-8750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1908 GLENWOOD PARK RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24739-7969
Practice Address - Country:US
Practice Address - Phone:304-323-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant