Healthcare Provider Details

I. General information

NPI: 1578757464
Provider Name (Legal Business Name): TUPPER D GILLIE SR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

IV. Provider business mailing address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax: 703-878-8735
Mailing address:
  • Phone: 703-490-1112
  • Fax: 703-878-8735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305005275
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number7657
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: