Healthcare Provider Details

I. General information

NPI: 1699142828
Provider Name (Legal Business Name): ALISSA SULLIVAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7912 JOURNEY LN
SPRINGFIELD VA
22153-2725
US

IV. Provider business mailing address

7912 JOURNEY LN
SPRINGFIELD VA
22153-2725
US

V. Phone/Fax

Practice location:
  • Phone: 703-973-8031
  • Fax:
Mailing address:
  • Phone: 703-973-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305209527
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305209527
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: