Healthcare Provider Details

I. General information

NPI: 1578890612
Provider Name (Legal Business Name): MARCIA BETH GRADDON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 ARMY NAVY DR STE 300
ARLINGTON VA
22206-2905
US

IV. Provider business mailing address

2445 ARMY NAVY DR STE 300
ARLINGTON VA
22206-2905
US

V. Phone/Fax

Practice location:
  • Phone: 703-769-8420
  • Fax: 703-553-8647
Mailing address:
  • Phone: 703-769-8420
  • Fax: 703-553-8647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000739
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: