Healthcare Provider Details

I. General information

NPI: 1871005769
Provider Name (Legal Business Name): STEPHANIE LEARISH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

1350 BEVERLY RD APT 712
MC LEAN VA
22101-3922
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 717-649-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: