Provider Demographics
NPI:1730604745
Name:FUNCTIONAL PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN SICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CMFT
Authorized Official - Phone:301-602-3117
Mailing Address - Street 1:7509 OLD CHAPEL DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-6011
Mailing Address - Country:US
Mailing Address - Phone:301-602-3117
Mailing Address - Fax:
Practice Address - Street 1:103 N ADAMS ST STE 1-2
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2256
Practice Address - Country:US
Practice Address - Phone:301-602-3117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD264742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty