Provider Demographics
NPI:1922470004
Name:GANT, LAURA LEE (MSPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:GANT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14906 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4016
Mailing Address - Country:US
Mailing Address - Phone:703-491-6167
Mailing Address - Fax:
Practice Address - Street 1:14906 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4016
Practice Address - Country:US
Practice Address - Phone:703-491-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202208225100000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist