Provider Demographics
NPI:1790548642
Name:SHAPES PHYSICAL THERAPY & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:SHAPES PHYSICAL THERAPY & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHAISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-212-9661
Mailing Address - Street 1:825 FERNDALE TER NE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4872
Mailing Address - Country:US
Mailing Address - Phone:509-212-9661
Mailing Address - Fax:
Practice Address - Street 1:19441 GOLF VISTA PLZ STE 110
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8270
Practice Address - Country:US
Practice Address - Phone:509-212-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty