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General NPI Number Information
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NPI Number | 1093395394
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Entity Type | Individual
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Provider Name | THOMAS RYAN SHORT LPTA, LMT
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Gender | Male
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Dates
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Enumeration Date | 04/11/2021
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Last Update Date | 04/11/2021
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Provider Practice Location Address
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Address Line | 1936 OPITZ BLVD STE A
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3360
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Country | US
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Telephone | 540-841-4443
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Fax |
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Provider Business Mailing Address
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Address Line | 4060 WESTWIND DR
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City | WOODBRIDGE
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State | VA
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Zip | 22193-5168
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Country | US
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Telephone | 703-927-5395
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 0019011669
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306605845
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License Number State | VA
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