Basic Information
| Provider Information | |||||||||
| NPI: | 1558764944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUDER | ||||||||
| FirstName: | BRITTANY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8270 WILLOW OAKS CORPORATE DR STE 700 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105218 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2014 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0377671 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTL.0013180 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305214188 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9000144219 | 05 | CO | MEDICAID |