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General NPI Number Information
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NPI Number | 1417686494
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Entity Type | Individual
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Provider Name | CORNELIUS LICLIC LPTA
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Gender | Male
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 06/06/2022
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Provider Practice Location Address
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Address Line | 7501 HERITAGE VILLAGE PLZ
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City | GAINESVILLE
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State | VA
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Zip | 20155-3078
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Country | US
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Telephone | 210-542-5623
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Fax |
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Provider Business Mailing Address
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Address Line | 12507 QUARTERHORSE LN
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City | WOODBRIDGE
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State | VA
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Zip | 22192-6371
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2306604819
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License Number State | VA
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