Basic Information
| Provider Information | |||||||||
| NPI: | 1255983516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECK | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2386B HICKORY NUT LN | ||||||||
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| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201712841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402479163 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2978 CENTREVILLE RD | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201716253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039345000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2019 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119-008157 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.