Healthcare Provider Details

I. General information

NPI: 1225161797
Provider Name (Legal Business Name): MARY R LYNN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 N GAYTON RD
RICHMOND VA
23233-7017
US

IV. Provider business mailing address

13209 CANTERBURY RD
MONTPELIER VA
23192-2646
US

V. Phone/Fax

Practice location:
  • Phone: 804-364-6352
  • Fax: 804-364-6070
Mailing address:
  • Phone: 804-883-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306000485
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: