Provider Demographics
NPI:1053950550
Name:STUART, CORY THOMAS (PT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:THOMAS
Last Name:STUART
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 MILLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1261
Mailing Address - Country:US
Mailing Address - Phone:803-851-3506
Mailing Address - Fax:803-619-9551
Practice Address - Street 1:1105 12TH ST
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3304
Practice Address - Country:US
Practice Address - Phone:803-973-0100
Practice Address - Fax:803-973-0117
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist