Healthcare Provider Details

I. General information

NPI: 1033678941
Provider Name (Legal Business Name): ANNIE GOLOVCSENKO PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13890 BRADDOCK RD STE 207
CENTREVILLE VA
20121-2437
US

IV. Provider business mailing address

38 MOON HILL RD
LEXINGTON MA
02421-6113
US

V. Phone/Fax

Practice location:
  • Phone: 540-720-2261
  • Fax: 540-720-5660
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305211970
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: