Provider Demographics
NPI:1093194300
Name:WAHBA, MIRA (PT)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:WAHBA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1672
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:703-239-2301
Practice Address - Street 1:8316 ARLINGTON BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5207
Practice Address - Country:US
Practice Address - Phone:703-205-1919
Practice Address - Fax:703-205-1977
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAK949-0081OtherCAREFIRST