Provider Demographics
NPI:1578861316
Name:LAKE-GREEN, LAURIE LEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LEE
Last Name:LAKE-GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-4037
Mailing Address - Country:US
Mailing Address - Phone:540-423-5427
Mailing Address - Fax:
Practice Address - Street 1:140 BRIMLEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-5103
Practice Address - Country:US
Practice Address - Phone:540-752-0111
Practice Address - Fax:540-752-0393
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001788225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant