Individual
CORNELIUS LICLIC
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPTA
Contact information
Practice address
7501 HERITAGE VILLAGE PLZ, GAINESVILLE, VA 20155-3078
(210) 542-5623
Mailing address
12507 QUARTERHORSE LN, WOODBRIDGE, VA 22192-6371
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2306604819
VA
Other
Enumeration date
06/06/2022
Last updated
06/06/2022
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