Provider Demographics
NPI:1487012332
Name:REDD, ANTHONY (PTA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:REDD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 794
Mailing Address - Street 2:
Mailing Address - City:FIELDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24089-0794
Mailing Address - Country:US
Mailing Address - Phone:276-806-0580
Mailing Address - Fax:
Practice Address - Street 1:4920 WOODMAR DR SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1651
Practice Address - Country:US
Practice Address - Phone:866-450-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604123225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant