Provider Demographics
NPI:1790242501
Name:LAMB, PHILLIP
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:LAMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 YADKIN RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-2200
Mailing Address - Country:US
Mailing Address - Phone:757-337-8776
Mailing Address - Fax:
Practice Address - Street 1:2808 YADKIN RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-2200
Practice Address - Country:US
Practice Address - Phone:757-337-8776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012569225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019012569OtherMASSAGE THERAPY LICENSE