Provider Demographics
NPI:1588332621
Name:SAMUELS, LAURA ASHLEY (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ASHLEY
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-5159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4720 PUDDLEDOCK RD STE 130
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1275
Practice Address - Country:US
Practice Address - Phone:804-520-7779
Practice Address - Fax:866-463-3047
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist