Healthcare Provider Details

I. General information

NPI: 1992052096
Provider Name (Legal Business Name): LYNNE J. GANZ, OTR/L, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11708 BOWMAN GREEN DR
RESTON VA
20190-3501
US

IV. Provider business mailing address

11708 BOWMAN GREEN DR
RESTON VA
20190-3501
US

V. Phone/Fax

Practice location:
  • Phone: 703-796-9887
  • Fax:
Mailing address:
  • Phone: 703-796-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119000014
License Number StateVA

VIII. Authorized Official

Name: MS. LYNNE J GANZ
Title or Position: DIRECTOR/OWNER
Credential: OTR
Phone: 703-796-9887