Healthcare Provider Details

I. General information

NPI: 1902870843
Provider Name (Legal Business Name): MEGHANN KIERSTEN BRUNBERG ATC, CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20098 ASHBROOK PL SUITE 190
ASHBURN VA
20147-3393
US

IV. Provider business mailing address

230 CANYON RD
WINCHESTER VA
22602-7024
US

V. Phone/Fax

Practice location:
  • Phone: 703-434-3316
  • Fax:
Mailing address:
  • Phone: 540-894-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000734
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number0019007230
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: