Provider Demographics
NPI:1518393099
Name:SIELLER, RICHARD THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:SIELLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:6970 FOX HUNT LN
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5394
Practice Address - Country:US
Practice Address - Phone:804-694-8111
Practice Address - Fax:804-694-5574
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003444225100000X
NY036867225100000X
VA2305003777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherMEDICARE GROUP PTAN
VA1518393099OtherMEDICAID QMB ONLY
VA1518393099OtherMEDICAID QMB ONLY