Provider Demographics
NPI:1871598417
Name:LAKE RIDGE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:LAKE RIDGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-730-6969
Mailing Address - Street 1:12544 DILLINGHAM SQ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5259
Mailing Address - Country:US
Mailing Address - Phone:703-730-6969
Mailing Address - Fax:703-730-1169
Practice Address - Street 1:12544 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5259
Practice Address - Country:US
Practice Address - Phone:703-730-6969
Practice Address - Fax:703-730-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004216225100000X
VA2305202401225100000X
VA2305003984225100000X
VA2305004144225100000X
VA2305006554225100000X
VA2305204490225100000X
VA2305207715225100000X
VA2305003338225100000X
VA2306602926225100000X
VA2306602599225100000X
VA2306602710225100000X
VA2306603622225100000X
VA2306603587225100000X
VA2306603592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S427OtherCAREFIRST
VA1871598417Medicaid