Healthcare Provider Details

I. General information

NPI: 1841683869
Provider Name (Legal Business Name): LAKE CHAMPLAIN PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2786 MAIN ST
CROWN POINT NY
12928
US

IV. Provider business mailing address

2786MAIN STREET
CROWN POINT NY
12928
US

V. Phone/Fax

Practice location:
  • Phone: 518-597-3384
  • Fax:
Mailing address:
  • Phone: 518-597-4678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030350-1
License Number StateNY

VIII. Authorized Official

Name: LEONARDO S LOPES-GOMES
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: P.T.
Phone: 518-597-3384