Healthcare Provider Details

I. General information

NPI: 1225167257
Provider Name (Legal Business Name): TRACY SHIPLETT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY K HAUK PT

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9685 MAIN ST STE B
FAIRFAX VA
22031-3752
US

IV. Provider business mailing address

9685 MAIN ST STE B
FAIRFAX VA
22031-3752
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305202398
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: