Basic Information
Provider Information | |||||||||
NPI: | 1023220001 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPAR | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | KIM | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SNEGAROFF | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | KIM | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1769 | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201181769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5406878181 | ||||||||
FaxNumber: | 5406878256 | ||||||||
Practice Location | |||||||||
Address1: | 150 ELDEN ST | ||||||||
Address2: | SUITE 242 | ||||||||
City: | HERNDON | ||||||||
State: | VA | ||||||||
PostalCode: | 201704861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7036893737 | ||||||||
FaxNumber: | 7036893889 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 10/25/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305203592 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.