1346631116 NPI number — ADVANCED KINETICS PHYSICAL THERAPY

Table of content: NICOLE WAGONER LCMHC (NPI 1477015881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346631116 NPI number — ADVANCED KINETICS PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED KINETICS PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346631116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 W ANNANDALE RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
FALLS CHURCH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22046-4226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-988-4664
Provider Business Mailing Address Fax Number:
571-295-7548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 W ANNANDALE RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22046-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-988-4664
Provider Business Practice Location Address Fax Number:
571-295-7548
Provider Enumeration Date:
02/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER, PHYSICAL THERAPIST
Authorized Official Telephone Number:
703-988-4664

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  2305203526 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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