Healthcare Provider Details

I. General information

NPI: 1245741024
Provider Name (Legal Business Name): PHYSICAL THERAPY YOUR WAY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9447B LORTON MARKET ST STE 250
LORTON VA
22079-1963
US

IV. Provider business mailing address

9447B LORTON MARKET ST STE 250
LORTON VA
22079-1963
US

V. Phone/Fax

Practice location:
  • Phone: 703-372-5716
  • Fax: 703-372-5716
Mailing address:
  • Phone: 703-372-5716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305003310
License Number StateVA

VIII. Authorized Official

Name: MRS. MARY P NALLS
Title or Position: DIRECTOR
Credential: PT
Phone: 703-338-3975