MEDICARE: SHANE MONDLOCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305217306	VA

General Provider Information

NPI Number	:	1073328241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE MONDLOCH

Provider Business Mailing Address
First Line	:	6671 COLTON CRAWFORD CIR
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22042-2267
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 N GEORGE MASON DR STE 504
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3670
Country	:	US
Telephone Number	:	703-525-2220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2025
Last Update Date	:	08/09/2025

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Directions to “ SHANE MONDLOCH ” Practice Location

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