Provider Demographics
NPI:1992348569
Name:SUMMIT PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:REEVES
Authorized Official - Last Name:VOLLERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-707-8107
Mailing Address - Street 1:2379 CAROLINA CHERRY CT
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3373
Mailing Address - Country:US
Mailing Address - Phone:360-707-8107
Mailing Address - Fax:
Practice Address - Street 1:2219 COUNTY ROAD 220 STE 304
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-7778
Practice Address - Country:US
Practice Address - Phone:360-707-8107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-25
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty