Healthcare Provider Details

I. General information

NPI: 1770225674
Provider Name (Legal Business Name): REACH PEDIATRIC REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8229 BOONE BLVD STE 260
VIENNA VA
22182-2661
US

IV. Provider business mailing address

8229 BOONE BLVD STE 260
VIENNA VA
22182-2661
US

V. Phone/Fax

Practice location:
  • Phone: 571-310-2502
  • Fax: 571-413-0290
Mailing address:
  • Phone: 571-310-2502
  • Fax: 571-413-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY LORAINE DAUER PHAM
Title or Position: OWNER
Credential: MD
Phone: 571-310-2502