Healthcare Provider Details

I. General information

NPI: 1699406975
Provider Name (Legal Business Name): CARISSA ERIN WORTHAM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2022
Last Update Date: 06/18/2022
Certification Date: 05/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6564 LOISDALE CT STE 500
SPRINGFIELD VA
22150-1823
US

IV. Provider business mailing address

17872 LOUNSBERY DR
DUMFRIES VA
22026-2639
US

V. Phone/Fax

Practice location:
  • Phone: 703-232-7977
  • Fax:
Mailing address:
  • Phone: 703-232-7977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: