Healthcare Provider Details

I. General information

NPI: 1629315411
Provider Name (Legal Business Name): PREMIER PEDIATRIC THERAPY SOURCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 S ARLINGTON MILL DR # 534
ARLINGTON VA
22206-3402
US

IV. Provider business mailing address

2776 S ARLINGTON MILL DR # 534
ARLINGTON VA
22206-3402
US

V. Phone/Fax

Practice location:
  • Phone: 703-879-2479
  • Fax: 703-879-2803
Mailing address:
  • Phone: 703-879-2479
  • Fax: 703-879-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119005367
License Number StateVA

VIII. Authorized Official

Name: DR. DEBBIE ALLEN
Title or Position: PRESIDENT & CEO
Credential: OTD
Phone: 703-879-2479