Healthcare Provider Details

I. General information

NPI: 1619357035
Provider Name (Legal Business Name): AUGUSTA LERCH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13711 MARSH ROAD
BEALETON VA
22712
US

IV. Provider business mailing address

13711 MARSH ROAD
BEALETON VA
22712
US

V. Phone/Fax

Practice location:
  • Phone: 540-841-2150
  • Fax:
Mailing address:
  • Phone: 540-841-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306602745
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: