Provider Demographics
NPI:1093379042
Name:SHAY, ALEXIS DANIELLE (PT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:DANIELLE
Last Name:SHAY
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 1:12212 SELINE WAY
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2872
Mailing Address - Country:US
Mailing Address - Phone:301-461-7371
Mailing Address - Fax:
Practice Address - Street 1:1760 OLD MEADOW RD STE 200
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4330
Practice Address - Country:US
Practice Address - Phone:703-988-4664
Practice Address - Fax:571-289-4690
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052132912251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305213291OtherPT LICENSE