Healthcare Provider Details

I. General information

NPI: 1093378168
Provider Name (Legal Business Name): PHYSIALIGN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 SHELBURNE RD STE 190
SOUTH BURLINGTON VT
05403-7733
US

IV. Provider business mailing address

PO BOX 64823
BURLINGTON VT
05406-4823
US

V. Phone/Fax

Practice location:
  • Phone: 802-318-0581
  • Fax: 802-448-5951
Mailing address:
  • Phone: 802-318-0581
  • Fax: 802-448-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAUREN WEDAM
Title or Position: AUTHORIZED AGENT
Credential: PT, DPT
Phone: 802-318-0581