Provider Demographics
NPI:1508887951
Name:WIMBERLY, HARRELL EDWARD (PT CSCS)
Entity Type:Individual
Prefix:MR
First Name:HARRELL
Middle Name:EDWARD
Last Name:WIMBERLY
Suffix:
Gender:M
Credentials:PT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 NURSERY HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1407
Mailing Address - Country:US
Mailing Address - Phone:803-781-9989
Mailing Address - Fax:803-781-9989
Practice Address - Street 1:1706 NURSERY HILL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1407
Practice Address - Country:US
Practice Address - Phone:803-781-9989
Practice Address - Fax:803-781-9989
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC892225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0008Medicaid