Provider Demographics
NPI:1639568231
Name:HOLY CITY PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:HOLY CITY PEDIATRIC THERAPY LLC
Other - Org Name:HOLY CITY PEDIATRIC THERAPY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLYE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:423-388-5198
Mailing Address - Street 1:142 SPORTSMAN ISLAND DR STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8524
Mailing Address - Country:US
Mailing Address - Phone:843-708-9138
Mailing Address - Fax:
Practice Address - Street 1:142 SPORTSMAN ISLAND DR STE E
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8524
Practice Address - Country:US
Practice Address - Phone:423-388-8311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X, 225X00000X, 235Z00000X
SC3907261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty