Healthcare Provider Details

I. General information

NPI: 1639780489
Provider Name (Legal Business Name): EVOLVE PHYSICAL THERAPY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 ALLAN RIDGE RD
MORRISTOWN VT
05661-8680
US

IV. Provider business mailing address

PO BOX 381
MORRISVILLE VT
05661-0381
US

V. Phone/Fax

Practice location:
  • Phone: 856-220-1460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LORI GOTTLIEB
Title or Position: PHYSICAL THERAPIST, OWNER
Credential: PT, DPT
Phone: 856-220-1460