Healthcare Provider Details

I. General information

NPI: 1548855141
Provider Name (Legal Business Name): ETHAN LANE CARROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6858 OLD DOMINION DR STE 200
MC LEAN VA
22101-3832
US

IV. Provider business mailing address

8496 CANYON OAK DR
SPRINGFIELD VA
22153-3576
US

V. Phone/Fax

Practice location:
  • Phone: 703-288-8260
  • Fax:
Mailing address:
  • Phone: 540-327-6188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605698
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: