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General NPI Number Information
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NPI Number | 1326558925
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Entity Type | Individual
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Provider Name | PHONGPHAN ROACH
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Gender | Female
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Dates
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Enumeration Date | 10/09/2017
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Last Update Date | 10/09/2017
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Provider Practice Location Address
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Address Line | 2980 CENTREVILLE RD
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City | HERNDON
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State | VA
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Zip | 20171-6254
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Country | US
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Telephone | 703-994-4561
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Fax |
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Provider Business Mailing Address
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Address Line | 1912 VILLARIDGE DR UNIT B
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City | RESTON
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State | VA
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Zip | 20191-4830
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Country | US
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Telephone | 916-450-1203
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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 | 225XP0019X
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Taxonomy Name | Physical Rehabilitation Occupational Therapist
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License Number | 0131001567
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License Number State | VA
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