Healthcare Provider Details

I. General information

NPI: 1962567271
Provider Name (Legal Business Name): PHILIP BENNETT LOTT LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19441 GOLF VISTA PLAZA SUITE 230
LEESBURG VA
20176
US

IV. Provider business mailing address

15110 CARLBERN DR
CENTREVILLE VA
20120-1431
US

V. Phone/Fax

Practice location:
  • Phone: 703-724-7474
  • Fax:
Mailing address:
  • Phone: 703-803-3043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306001158
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: