Healthcare Provider Details

I. General information

NPI: 1598643769
Provider Name (Legal Business Name): TARA ESMAEILI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12436 DILLINGHAM SQ
LAKE RIDGE VA
22192-5258
US

IV. Provider business mailing address

11147 BYRD DR
FAIRFAX VA
22030-5364
US

V. Phone/Fax

Practice location:
  • Phone: 703-340-2921
  • Fax:
Mailing address:
  • Phone: 571-839-1892
  • Fax: 571-839-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305217373
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: