Provider Demographics
NPI:1083187447
Name:PENA-MOOG, HEIDI (LPTA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PENA-MOOG
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2550
Mailing Address - Country:US
Mailing Address - Phone:703-277-6611
Mailing Address - Fax:
Practice Address - Street 1:9229 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2550
Practice Address - Country:US
Practice Address - Phone:703-277-6611
Practice Address - Fax:703-383-0206
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001382225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant