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General NPI Number Information
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NPI Number | 1245593029
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Entity Type | Individual
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Provider Name | KATHRYN ELIZABETH CANYON PTA
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Gender | Female
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Dates
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Enumeration Date | 06/18/2012
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Last Update Date | 06/18/2012
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Provider Practice Location Address
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Address Line | 4001 FAIR RIDGE DR SUITE 203
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City | FAIRFAX
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State | VA
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Zip | 22033-2917
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Country | US
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Telephone | 703-865-7680
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Fax | 703-865-7683
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Provider Business Mailing Address
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Address Line | 11084 WAINWRIGHT PL
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City | MANASSAS
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State | VA
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Zip | 20109-8274
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Country | US
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Telephone | 703-881-8201
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306602837
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License Number State | VA
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