Healthcare Provider Details

I. General information

NPI: 1164741237
Provider Name (Legal Business Name): CASSIE EDGREEN MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7617 LITTLE RIVER TPKE 310
ANNANDALE VA
22003-2603
US

IV. Provider business mailing address

7617 LITTLE RIVER TPKE 310
ANNANDALE VA
22003-2603
US

V. Phone/Fax

Practice location:
  • Phone: 703-750-2443
  • Fax: 703-941-0587
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119005108
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: