Healthcare Provider Details

I. General information

NPI: 1477543718
Provider Name (Legal Business Name): BILLIE JANE RANDOLPH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BILLIE JANE MIELCAREK

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-0004
US

IV. Provider business mailing address

6394 TRUE LN
SPRINGFIELD VA
22150-1030
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4611
  • Fax:
Mailing address:
  • Phone: 703-971-5769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305204969
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: