Basic Information
| Provider Information | |||||||||
| NPI: | 1770055956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLLACKER | ||||||||
| FirstName: | LAUREN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 NEEDY RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254056200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408775003 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 11116 MEDICAL CAMPUS RD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017908000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2018 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2306605182 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | A5025 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.