=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710324215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFETIME THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2013
-----------------------------------------------------
Last Update Date | 08/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14573 POTOMAC MILLS RD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-6808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-203-7468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14573 POTOMAC MILLS RD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-6808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-203-7468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | LIANA RENEE TOYER
-----------------------------------------------------
Credential | M.A. CC-SLP
-----------------------------------------------------
Telephone | 703-507-5525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2202005537
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------