Provider Demographics
NPI:1245431055
Name:SLY, TIMOTHY S (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:S
Last Name:SLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15642 SHADY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-3018
Mailing Address - Country:US
Mailing Address - Phone:218-631-2025
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1264
Practice Address - Country:US
Practice Address - Phone:218-631-7475
Practice Address - Fax:218-632-8765
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist