Healthcare Provider Details

I. General information

NPI: 1588342869
Provider Name (Legal Business Name): MOVEMENT PERFORMANCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7439 LINTON HALL RD
GAINESVILLE VA
20155-2977
US

IV. Provider business mailing address

21816 CRESCENT PARK SQ STE 1816
BROADLANDS VA
20148-4418
US

V. Phone/Fax

Practice location:
  • Phone: 571-215-3172
  • Fax: 571-386-2534
Mailing address:
  • Phone: 571-215-3172
  • Fax: 571-386-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROL M CANTELLO
Title or Position: PRESIDENT
Credential: OTR/L, CCTP,CCBHP
Phone: 571-215-3172