Basic Information
| Provider Information | |||||||||
| NPI: | 1164545034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11922 SLOANE CT | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201912726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038600316 | ||||||||
| FaxNumber: | 7038600316 | ||||||||
| Practice Location | |||||||||
| Address1: | 6849 OLD DOMINION DR | ||||||||
| Address2: | SUITE 221 | ||||||||
| City: | MCLEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038489333 | ||||||||
| FaxNumber: | 7038480660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305202432 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.