Healthcare Provider Details

I. General information

NPI: 1093199275
Provider Name (Legal Business Name): HAYMARKET PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 12/06/2023
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14535 JOHN MARSHALL HWY 203
GAINESVILLE VA
20155-4023
US

IV. Provider business mailing address

14535 JOHN MARSHALL HWY STE 203
GAINESVILLE VA
20155-4025
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-0974
  • Fax:
Mailing address:
  • Phone: 703-753-0261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305207830
License Number StateVA

VIII. Authorized Official

Name: JESSICA HOLDAWAY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 571-719-3563