Provider Demographics
NPI:1255963237
Name:TRELLIS PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:TRELLIS PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DISMUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-202-2123
Mailing Address - Street 1:2507 LOCUST HILL RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-9698
Mailing Address - Country:US
Mailing Address - Phone:423-202-2123
Mailing Address - Fax:
Practice Address - Street 1:2507 LOCUST HILL RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-9698
Practice Address - Country:US
Practice Address - Phone:423-202-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty