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General NPI Number Information
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NPI Number | 1578909487
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Entity Type | Organization
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Legal Business Name | VITAL SELF PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 05/18/2013
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Last Update Date | 06/18/2013
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Provider Practice Location Address
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Address Line | 7610 PENNSYLVANIA AVE
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City | FORESTVILLE
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State | MD
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Zip | 20747-4701
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Country | US
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Telephone | 313-550-6367
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Fax | 301-669-1873
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Provider Business Mailing Address
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Address Line | 7610 PENNSYLVANIA AVE
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City | FORESTVILLE
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State | MD
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Zip | 20747-4701
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Country | US
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Telephone | 313-550-6367
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Fax | 301-669-1873
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | LAUREN H COLLINS
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Credential | MPT, CLT-LANA
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Telephone | 313-550-6367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 24460
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License Number State | MD
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