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General NPI Number Information
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NPI Number | 1982097465
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Entity Type | Organization
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Legal Business Name | PROACTIVE PHYSICAL THERAPY AND WELLNESS LLC
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Dates
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Enumeration Date | 03/09/2015
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Last Update Date | 08/03/2015
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Provider Practice Location Address
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Address Line | 3903 FAIR RIDGE DR 211
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City | FAIRFAX
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State | VA
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Zip | 22033-2943
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Country | US
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Telephone | 571-294-3557
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Fax |
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Provider Business Mailing Address
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Address Line | 3903 FAIR RIDGE DR 211
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City | FAIRFAX
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State | VA
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Zip | 22033-2943
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Country | US
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Telephone | 571-294-3557
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MRS. CHAVONE JOHNSON
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Credential |
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Telephone | 571-294-3557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2305204873
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License Number State | VA
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