Provider Demographics
NPI:1174838510
Name:CONOVER, BRENT (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:CONOVER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630680
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263
Mailing Address - Country:US
Mailing Address - Phone:703-709-1116
Mailing Address - Fax:571-323-6138
Practice Address - Street 1:1831 WIEHLE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-709-1116
Practice Address - Fax:571-323-6138
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist