Healthcare Provider Details

I. General information

NPI: 1255717575
Provider Name (Legal Business Name): CHARA CIVITELLO OCCUPATIONAL THERAPY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5804 CHASE COMMONS COURT APT 207
BURKE VA
22015
US

IV. Provider business mailing address

5804 CHASE COMMONS CT APT 207
BURKE VA
22015-4640
US

V. Phone/Fax

Practice location:
  • Phone: 323-350-8395
  • Fax:
Mailing address:
  • Phone: 323-350-8395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number0119006625
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: