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General NPI Number Information
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NPI Number | 1720804339
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Entity Type | Individual
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Provider Name | MAMTA U BOLADE PT
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Gender | Female
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Dates
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Enumeration Date | 11/27/2024
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Last Update Date | 11/27/2024
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Provider Practice Location Address
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Address Line | 24790 MEADOWS FARMS CT
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City | SOUTH RIDING
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State | VA
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Zip | 20152-3000
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Country | US
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Telephone | 703-372-4445
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Fax | 703-957-3365
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Provider Business Mailing Address
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Address Line | 25476 HARTLAND ORCHARD TER
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City | SOUTH RIDING
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State | VA
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Zip | 20152-3268
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Country | US
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Telephone | 202-487-0563
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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 | 2305216674
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License Number State | VA
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