Provider Demographics
NPI:1447724539
Name:PETERS, DYLAN SCOTT (PT, DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:SCOTT
Last Name:PETERS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:9241 UNIVERSITY BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9349
Practice Address - Country:US
Practice Address - Phone:843-764-4887
Practice Address - Fax:843-764-4509
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014368225100000X
TN12103225100000X
SC11772225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist