Provider Demographics
NPI:1619401809
Name:ELLIOTT, LARRY JR (PTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:ELLIOTT
Suffix:JR
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 1:548 SWEET PEACH LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6943
Mailing Address - Country:US
Mailing Address - Phone:803-547-3049
Mailing Address - Fax:
Practice Address - Street 1:831 MCDOW DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2415
Practice Address - Country:US
Practice Address - Phone:803-366-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1580225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant