Healthcare Provider Details

I. General information

NPI: 1134727357
Provider Name (Legal Business Name): ELENA IGOREVNA SUTPHIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 OPITZ BLVD STE A
WOODBRIDGE VA
22191-3360
US

IV. Provider business mailing address

35332 QUAIL MEADOW LN
LOCUST GROVE VA
22508-3116
US

V. Phone/Fax

Practice location:
  • Phone: 540-841-4443
  • Fax:
Mailing address:
  • Phone: 929-272-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number2306605532
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2306605532
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: