Healthcare Provider Details

I. General information

NPI: 1053947705
Provider Name (Legal Business Name): LAUREN MAXWELL PT,DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672 NAFF RD
BOONES MILL VA
24065-1992
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-9813
  • Fax: 540-985-4066
Mailing address:
  • Phone: 540-224-5715
  • Fax: 540-224-5684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number2305205520
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305205520
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: