MEDICARE: MRS. LISA GAY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305003496	VA

General Provider Information

NPI Number	:	1801098652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA GAY PT

Provider Business Mailing Address
First Line	:	15139 WETHERBURN DR
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20120-3925
Country	:	US
Telephone Number	:	703-830-3717
Fax Number	:

Provider Business Practice Location Address
First Line	:	13350 FRANKLIN FARM RD
Second Line	:	STE. 300
City	:	HERNDON
State	:	VA
Zip	:	20171-4091
Country	:	US
Telephone Number	:	703-234-1045
Fax Number	:	703-471-0280

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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