Provider Demographics
NPI:1093093601
Name:ECCLES, ANNETTE (NCTMBW, LMT)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:ECCLES
Suffix:
Gender:F
Credentials:NCTMBW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23510 SPINNING WHEEL CT
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2488
Mailing Address - Country:US
Mailing Address - Phone:571-373-2042
Mailing Address - Fax:
Practice Address - Street 1:4229 LAFAYETTE CENTER DR STE 1900
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1260
Practice Address - Country:US
Practice Address - Phone:571-373-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009023225700000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist