Healthcare Provider Details

I. General information

NPI: 1962407411
Provider Name (Legal Business Name): HADI FATHALIKHANI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12546 DILLINGHAM SQ # 101
WOODBRIDGE VA
22192-5259
US

IV. Provider business mailing address

14014 SULLYFIELD CIR STE B
CHANTILLY VA
20151-1689
US

V. Phone/Fax

Practice location:
  • Phone: 703-730-6969
  • Fax: 703-730-1169
Mailing address:
  • Phone: 703-263-2020
  • Fax: 703-263-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305003984
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: