Basic Information
| Provider Information | |||||||||
| NPI: | 1093334732 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CENTRA | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | N CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045605595 | ||||||||
| FaxNumber: | 8049681803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1760 OLD MEADOW ROAD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | MCLEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221024330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105214 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 010001734 | DC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 0119008514 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.