Healthcare Provider Details

I. General information

NPI: 1801238316
Provider Name (Legal Business Name): PETYA DJOUBRAILOV PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CHURCH ST NE STE 115
VIENNA VA
22180-4734
US

IV. Provider business mailing address

PO BOX 173
OAKTON VA
22124-0173
US

V. Phone/Fax

Practice location:
  • Phone: 703-679-8078
  • Fax:
Mailing address:
  • Phone: 703-679-8078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019008522
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208035
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: