Basic Information
| Provider Information | |||||||||
| NPI: | 1477636686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AQUATIC THERAPY OF VIRGINIA, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 OYSTER POINT RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236026014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572690430 | ||||||||
| FaxNumber: | 7572690432 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 OYSTER POINT RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236026014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572690430 | ||||||||
| FaxNumber: | 7572690432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GARRETT | ||||||||
| AuthorizedOfficialFirstName: | GWENDOLYN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7572690430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119001200 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.