Basic Information
Provider Information | |||||||||
NPI: | 1003267857 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KULP | ||||||||
FirstName: | BRETT | ||||||||
MiddleName: | ALEXANDRIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GLADISH | ||||||||
OtherFirstName: | BRETT | ||||||||
OtherMiddleName: | ALEXANDRIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 43490 YUKON DR | ||||||||
Address2: | SUITE 212 | ||||||||
City: | ASHBURN | ||||||||
State: | VA | ||||||||
PostalCode: | 201476990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037297920 | ||||||||
FaxNumber: | 7037297923 | ||||||||
Practice Location | |||||||||
Address1: | 43490 YUKON DR | ||||||||
Address2: | SUITE 212 | ||||||||
City: | ASHBURN | ||||||||
State: | VA | ||||||||
PostalCode: | 201476990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037297920 | ||||||||
FaxNumber: | 7037297923 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2016 | ||||||||
LastUpdateDate: | 06/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.