Healthcare Provider Details

I. General information

NPI: 1104117852
Provider Name (Legal Business Name): MARIELLE ISENBERG ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 GREENSBORO DR STE 120
MC LEAN VA
22102-5101
US

IV. Provider business mailing address

10215 FERNWOOD RD STE 506
BETHESDA MD
20817-1184
US

V. Phone/Fax

Practice location:
  • Phone: 301-530-1010
  • Fax: 301-897-8597
Mailing address:
  • Phone: 301-530-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number050702076
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: