Provider Demographics
NPI:1821170267
Name:GWYNN, LAURA HARRIS (MPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:HARRIS
Last Name:GWYNN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WHITE DOGWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-4167
Mailing Address - Country:US
Mailing Address - Phone:757-819-7827
Mailing Address - Fax:
Practice Address - Street 1:2200 COLONIAL AVENUE SUITE 2
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517
Practice Address - Country:US
Practice Address - Phone:757-622-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004289225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist