Healthcare Provider Details

I. General information

NPI: 1710449863
Provider Name (Legal Business Name): SUSAN WINDLEY OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

6613 NETTIES LN UNIT D
ALEXANDRIA VA
22315-6090
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 703-628-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131002021
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: