Healthcare Provider Details

I. General information

NPI: 1285595249
Provider Name (Legal Business Name): VIRGINIA MOTTLA PT, DPT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 3RD AVE FL 9
NEW YORK NY
10021-2963
US

IV. Provider business mailing address

3806 20TH RD
ASTORIA NY
11105-1626
US

V. Phone/Fax

Practice location:
  • Phone: 212-439-1596
  • Fax:
Mailing address:
  • Phone: 617-633-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number055269
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: