Provider Demographics
NPI:1902804073
Name:WASHBURN, LAWRENCE MATTHEW (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:MATTHEW
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 288
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-0288
Mailing Address - Country:US
Mailing Address - Phone:731-587-3422
Mailing Address - Fax:731-587-3424
Practice Address - Street 1:104 OXFORD ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-2428
Practice Address - Country:US
Practice Address - Phone:731-587-3422
Practice Address - Fax:731-587-3424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4072042OtherPHYSICAL THERAPIST
TN3717871Medicaid
TN4072042OtherPHYSICAL THERAPIST