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General NPI Number Information
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NPI Number | 1215236690
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE PHYSICAL THERAPY AND WELLNESS
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Dates
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Enumeration Date | 03/24/2011
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Last Update Date | 05/12/2014
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Provider Practice Location Address
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Address Line | 512 HERNDON PKWY STE F SUITE 120
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City | HERNDON
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State | VA
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Zip | 20170-5244
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Country | US
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Telephone | 786-882-7786
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Fax |
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Provider Business Mailing Address
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Address Line | 512 HERNDON PARKWAY, SUITE F
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City | HERNDON
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State | VA
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Zip | 20170
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Country | US
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Telephone | 703-786-8827
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. STACY KEITH
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Credential | DPT, PT
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Telephone | 703-786-8827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2307000500
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License Number State | VA
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