MEDICARE: PAIGE GOODMAN

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	2255A2300X	Athletic Trainer	2751	MA
2	225100000X	Physical Therapist	2305215321	VA

General Provider Information

NPI Number	:	1811352834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAIGE GOODMAN

Provider Business Mailing Address
First Line	:	9731 DELLFORD CT
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-4165
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR STE 1250
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1266
Country	:	US
Telephone Number	:	703-263-2020
Fax Number	:	703-263-2015

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

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	08/22/2022

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Directions to “ PAIGE GOODMAN ” Practice Location

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