Basic Information
| Provider Information | |||||||||
| NPI: | 1821062209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THRELFALL | ||||||||
| FirstName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 IRVING ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200103017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015406140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12825 MINNIEVILLE RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221923601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039713701 | ||||||||
| FaxNumber: | 7036473126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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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 | 2831 | NH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305206415 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 010474 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 003120150A | 05 | GA | MEDICAID | 08Y004741NH01 | 01 | NH | ANTHEM | OTHER | 30392274 | 05 | NH | MEDICAID | 00800698 | 01 | GA | AMERIGROUP | OTHER |