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General NPI Number Information
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NPI Number | 1336622257
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE PEDIATRIC THERAPY
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Dates
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Enumeration Date | 09/07/2018
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Last Update Date | 09/07/2018
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Provider Practice Location Address
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Address Line | 150 S. WASHINGTON ST. #203
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City | FALLS CHURCH
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State | VA
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Zip | 22124
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Country | US
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Telephone | 703-606-6213
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Fax | 703-496-4779
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Provider Business Mailing Address
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Address Line | 150 S WASHINGTON ST STE 203
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City | FALLS CHURCH
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State | VA
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Zip | 22046-2921
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Country | US
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Telephone | 703-606-6213
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Fax | 703-496-4779
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Authorized Official
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Title or Position | OWNER, PHYSICAL THERAPIST
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Name | MRS. JILL KAREN WAGNER
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Credential | MS, PT
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Telephone | 703-606-6213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 0105005106
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License Number State | VA
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