Healthcare Provider Details

I. General information

NPI: 1346153509
Provider Name (Legal Business Name): INDRA STEPHENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 ROUTE 29 STE 720
FAIRFAX VA
22031-1531
US

IV. Provider business mailing address

7745 INVERSHAM DR APT 199
FALLS CHURCH VA
22042-4454
US

V. Phone/Fax

Practice location:
  • Phone: 571-251-5523
  • Fax:
Mailing address:
  • Phone: 571-251-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019020884
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: