Provider Demographics
NPI:1558551754
Name:COGDELL, THOMAS KELLY (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:KELLY
Last Name:COGDELL
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 1:11310 INVOLUTE PL APT 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8509
Mailing Address - Country:US
Mailing Address - Phone:919-692-1005
Mailing Address - Fax:919-692-1005
Practice Address - Street 1:500 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2543
Practice Address - Country:US
Practice Address - Phone:919-693-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3518225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant