Healthcare Provider Details

I. General information

NPI: 1245980341
Provider Name (Legal Business Name): LIBERTY SPORTS & PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PARK HILL DR
FREDERICKSBURG VA
22401-3377
US

IV. Provider business mailing address

501 PARK HILL DR
FREDERICKSBURG VA
22401-3377
US

V. Phone/Fax

Practice location:
  • Phone: 540-656-2786
  • Fax:
Mailing address:
  • Phone: 540-372-6745
  • Fax: 540-735-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: SHAWN CHANCE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 540-656-2786