Healthcare Provider Details

I. General information

NPI: 1154948933
Provider Name (Legal Business Name): MY PT AND PILATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6706 RED JACKET RD
SPRINGFIELD VA
22152-2633
US

IV. Provider business mailing address

6706 RED JACKET RD
SPRINGFIELD VA
22152-2633
US

V. Phone/Fax

Practice location:
  • Phone: 903-224-5058
  • Fax:
Mailing address:
  • Phone: 903-224-5058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEANNINE MARIE BURGETT
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 903-224-5058