Provider Demographics
NPI:1124371653
Name:MCCLURE, MILDRED LORETTA (LPTA)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:LORETTA
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11059 MOUNT CALM DR
Mailing Address - Street 2:
Mailing Address - City:GLADE SPRING
Mailing Address - State:VA
Mailing Address - Zip Code:24340-5011
Mailing Address - Country:US
Mailing Address - Phone:276-608-2578
Mailing Address - Fax:276-944-0952
Practice Address - Street 1:11059 MOUNT CALM DR
Practice Address - Street 2:
Practice Address - City:GLADE SPRING
Practice Address - State:VA
Practice Address - Zip Code:24340-5011
Practice Address - Country:US
Practice Address - Phone:276-608-2578
Practice Address - Fax:276-944-0952
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000461225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant