Basic Information
| Provider Information | |||||||||
| NPI: | 1073255618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSIS | ||||||||
| FirstName: | PETRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13582 BIG BOULDER RD | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201715000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713292658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 46531 HARRY BYRD HWY | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201643555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038345800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2022 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | A60879991 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.