Provider Demographics
NPI:1598861460
Name:LOOMIS, LAURA BETH (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:LOOMIS
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 1:2311 KEYES LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2011
Mailing Address - Country:US
Mailing Address - Phone:423-914-1095
Mailing Address - Fax:
Practice Address - Street 1:245 NORTH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3274
Practice Address - Country:US
Practice Address - Phone:276-669-4711
Practice Address - Fax:276-669-0834
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602165225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306602165OtherPTA LICENSE NUMBER
TNPTA0000003077OtherPTA LICENSE NUMBER