Provider Demographics
NPI:1982125100
Name:THERAPY 360, LLC
Entity Type:Organization
Organization Name:THERAPY 360, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GILES
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:202-257-4854
Mailing Address - Street 1:716 LEVY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5730
Mailing Address - Country:US
Mailing Address - Phone:1202-257-4854
Mailing Address - Fax:800-923-4304
Practice Address - Street 1:716 LEVY AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5730
Practice Address - Country:US
Practice Address - Phone:1202-257-4854
Practice Address - Fax:800-923-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty