MEDICARE: ELLA GRACE ROBERTS PT

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	208100000X	Physical Medicine & Rehabilitation Physician	2305217090	VA

General Provider Information

NPI Number	:	1316826860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLA GRACE ROBERTS PT

Provider Business Mailing Address
First Line	:	612 N KENMORE ST
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-2221
Country	:	US
Telephone Number	:	303-945-9473
Fax Number	:

Provider Business Practice Location Address
First Line	:	11507 SUNSET HILLS RD
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20190-4704
Country	:	US
Telephone Number	:	301-978-4838
Fax Number	:

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

Provider Enumeration Date	:	08/28/2025
Last Update Date	:	08/28/2025

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