Provider Demographics
NPI:1093974453
Name:CALLAIS, VIRGINIA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LYNN
Last Name:CALLAIS
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 1:424 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3310
Mailing Address - Country:US
Mailing Address - Phone:512-507-2966
Mailing Address - Fax:
Practice Address - Street 1:424 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3310
Practice Address - Country:US
Practice Address - Phone:512-507-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10431R225100000X
TX1181339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist