Healthcare Provider Details

I. General information

NPI: 1437847316
Provider Name (Legal Business Name): MATTHEW ADAM WACHTMAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MADISON ST STE LL2
ALEXANDRIA VA
22314-2065
US

IV. Provider business mailing address

111 WESTRIDGE DR STE F
FRANKFORT KY
40601-4448
US

V. Phone/Fax

Practice location:
  • Phone: 703-299-6688
  • Fax: 703-299-3588
Mailing address:
  • Phone: 502-227-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP034874T
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305216741
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: