Basic Information
| Provider Information | |||||||||
| NPI: | 1720219546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | ELISHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITNEY | ||||||||
| OtherFirstName: | ELISHA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1501 DUKE ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223143468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035355491 | ||||||||
| FaxNumber: | 7035355494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 DUKE ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223143468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035355491 | ||||||||
| FaxNumber: | 7035355494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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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 | PT871042 | DC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305206648 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.