Provider Demographics
NPI:1932687092
Name:DILLMAN, DOUGLAS (LMBT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:DILLMAN
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4849 SAMUEL RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-7605
Mailing Address - Country:US
Mailing Address - Phone:980-202-2024
Mailing Address - Fax:
Practice Address - Street 1:994 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2433
Practice Address - Country:US
Practice Address - Phone:980-202-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
NC9388225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty