MEDICARE: LAURA KATHERINE BRACKEN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305211898	VA

General Provider Information

NPI Number	:	1073006888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA KATHERINE BRACKEN PT, DPT

Provider Business Mailing Address
First Line	:	146 BASKINS RD
Second Line	:
City	:	LAKELAND
State	:	GA
Zip	:	31635-5222
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 LENFANT PLZ SW STE 602
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20024-9996
Country	:	US
Telephone Number	:	202-863-0430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	06/07/2018

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