Healthcare Provider Details

I. General information

NPI: 1952099202
Provider Name (Legal Business Name): MAKEDA FIKRE-SELASSIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12825 MINNIEVILLE RD STE 201
LAKE RIDGE VA
22192-3602
US

IV. Provider business mailing address

11961 CARDAMOM DR
WOODBRIDGE VA
22192-1435
US

V. Phone/Fax

Practice location:
  • Phone: 703-647-3130
  • Fax:
Mailing address:
  • Phone: 240-381-0853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305216833
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29642
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: