Healthcare Provider Details

I. General information

NPI: 1326820523
Provider Name (Legal Business Name): AUTUMN GRAY HOTTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 FIRST COLONIAL RD
VIRGINIA BEACH VA
23454-2418
US

IV. Provider business mailing address

1761 BRUCETOWN RD
CLEAR BROOK VA
22624-1114
US

V. Phone/Fax

Practice location:
  • Phone: 757-455-5000
  • Fax:
Mailing address:
  • Phone: 540-398-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606428
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: