Lake Ridge Physical Therapy, LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

2305004216 Issued in VA

Legal business name

LAKE RIDGE PHYSICAL THERAPY, LLC

Practice address

12544 Dillingham SQ
Woodbridge, VA 22192-5259

Phone

(703) 730-6969

Fax

(703) 730-1169

NPI assigned

Jun 20, 2005

Last updated

Sep 14, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Becky S Anderson

Title

Vice President/Practice Manager

Phone

(703) 730-6969

Specialties & licenses 14

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in VA

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871598417. Details of each certification follow.

• CCN 496675 Outpatient physical therapy / speech pathology · Active · Name & address match · Details

Outpatient physical therapy / speech pathology certification: CCN 496675

Legal name

LAKE RIDGE PHYSICAL THERAPY

Certification status

Active

Provider type (POS)

Outpatient physical therapy / speech pathology

Participating since

Jan 25, 2001

Last certification

Feb 12, 2024

Ownership / control type

Proprietary

Facility address

12544 Dillingham Square
Woodbridge, VA 22192

Locations

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Hadi Fathalikhani, PT

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1962407411
  NPD
• Christopher Greetham, PT

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1770588238
  NPD
• Aya Abdo

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1245063577
  NPD (past)
• Maria Cecilia Acevedo, P.T

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1518409747
  NPD (past)
• Brittany Lanell Blough, M.S.P.T.

  • Physical Therapist
  • Dumfries, VA
  • NPI 1336182559
  NPD (past)
• Douglas Kendrick Chan, PT

  • Physical Therapist
  • Dumfries, VA
  • NPI 1376616268
  NPD (past)
• Robert Cowley, PT, DPT, OCS

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1093214850
  NPD (past)
• Allison Edelstein

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1619594322
  NPD (past)
• John Freeman, DPT

  • Orthopedic Physical Therapist
  • Woodbridge, VA
  • NPI 1821715632
  NPD (past)
• Matthew Gordon, DPT

  • Physical Therapist
  • Woodbridge, VA
  • NPI 1275055071
  NPD (past)
• Imari Jeanine Heavens, PT,DPT

  • Orthopedic Physical Therapist
  • Woodbridge, VA
  • NPI 1043987795
  NPD (past)
• Brittney Holt, DPT

  • Physical Therapist
  • Fredericksburg, VA
  • NPI 1730677840
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119225600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663113600000",
    "number": "1871598417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12544 DILLINGHAM SQ",
            "city": "WOODBRIDGE",
            "state": "VA",
            "postal_code": "221925259",
            "telephone_number": "703-730-6969",
            "fax_number": "703-730-1169"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12544 DILLINGHAM SQ",
            "city": "WOODBRIDGE",
            "state": "VA",
            "postal_code": "221925259",
            "telephone_number": "703-730-6969",
            "fax_number": "703-730-1169"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE RIDGE PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-20",
        "last_updated": "2022-09-14",
        "certification_date": "2022-09-14",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "BECKY",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "VICE PRESIDENT/PRACTICE MANAGER",
        "authorized_official_telephone_number": "703-730-6969"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305004216",
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305202401",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305003984",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305004144",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305006554",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305204490",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305207715",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305003338",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306602926",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306602599",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306602710",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306603622",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306603587",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2306603592",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1871598417",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAREFIRST",
            "identifier": "S427",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Lakeridge Dental Associates
• Lakeridgesmiles
• Rebecca 'Becca' A Lakin, M.ED.

• Physical Therapist in Woodbridge, VA
• Providers in Woodbridge, VA by specialty
• Physical Therapist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.