Provider Demographics
NPI:1770603953
Name:PAGE, LORETTA YOUNG (OTRL)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:YOUNG
Last Name:PAGE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 TEMPLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2361
Mailing Address - Country:US
Mailing Address - Phone:540-890-2806
Mailing Address - Fax:
Practice Address - Street 1:5306 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3850
Practice Address - Country:US
Practice Address - Phone:540-362-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003862225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist