=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841933595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL PEDIATRIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2022
-----------------------------------------------------
Last Update Date | 04/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21750 RED RUM DR STE 117
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-5867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-574-2989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21750 RED RUM DR STE 117
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-5867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-574-2989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ASHLEY HEMINGWAY
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 703-505-7605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------