Healthcare Provider Details

I. General information

NPI: 1871598417
Provider Name (Legal Business Name): LAKE RIDGE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12544 DILLINGHAM SQ
WOODBRIDGE VA
22192-5259
US

IV. Provider business mailing address

12544 DILLINGHAM SQ
WOODBRIDGE VA
22192-5259
US

V. Phone/Fax

Practice location:
  • Phone: 703-730-6969
  • Fax: 703-730-1169
Mailing address:
  • Phone: 703-730-6969
  • Fax: 703-730-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305202401
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305003984
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305004144
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305006554
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305204490
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305207715
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305003338
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306602926
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306602599
License Number StateVA
# 10
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306602710
License Number StateVA
# 11
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306603622
License Number StateVA
# 12
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306603587
License Number StateVA
# 13
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2306603592
License Number StateVA
# 14
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305004216
License Number StateVA

VIII. Authorized Official

Name: BECKY S ANDERSON
Title or Position: VICE PRESIDENT/PRACTICE MANAGER
Credential:
Phone: 703-730-6969