Healthcare Provider Details

I. General information

NPI: 1184128506
Provider Name (Legal Business Name): ANDREW VAN HAREN PT,DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 CLIFTON ST
LYNCHBURG VA
24501-1422
US

IV. Provider business mailing address

207 CHELSEA DR
FOREST VA
24551-3019
US

V. Phone/Fax

Practice location:
  • Phone: 240-464-8725
  • Fax:
Mailing address:
  • Phone: 240-464-8725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305215061
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003255
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: