Provider Demographics
NPI:1578909487
Name:VITAL SELF PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:VITAL SELF PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:H
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CLT-LANA
Authorized Official - Phone:313-550-6367
Mailing Address - Street 1:7610 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-4701
Mailing Address - Country:US
Mailing Address - Phone:313-550-6367
Mailing Address - Fax:301-669-1873
Practice Address - Street 1:7610 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-4701
Practice Address - Country:US
Practice Address - Phone:313-550-6367
Practice Address - Fax:301-669-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24460261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy