Provider Demographics
NPI:1992988430
Name:VIRTUDAZO, VIVIEN (PT)
Entity type:Individual
Prefix:MS
First Name:VIVIEN
Middle Name:
Last Name:VIRTUDAZO
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 1:2941 SEASONS DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6799
Mailing Address - Country:US
Mailing Address - Phone:765-326-0277
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DRIVE
Practice Address - Street 2:LIFESPAN THERAPY
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-573-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009263A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist