Healthcare Provider Details

I. General information

NPI: 1578913737
Provider Name (Legal Business Name): THE CHILDREN'S THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 HERITAGE VILLAGE PLZ SUITE 175
GAINESVILLE VA
20155-3065
US

IV. Provider business mailing address

8348 TRAFORD LN SUITE 200
SPRINGFIELD VA
22152-1663
US

V. Phone/Fax

Practice location:
  • Phone: 703-291-1254
  • Fax: 571-248-0304
Mailing address:
  • Phone: 703-569-7500
  • Fax: 703-866-0158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1457491391
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202008072
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305001607
License Number StateVA

VIII. Authorized Official

Name: LISA MARIE MACKELL
Title or Position: PRESIDENT
Credential: PT
Phone: 484-787-2267