Provider Demographics
NPI:1194381178
Name:RANE, MAYURA JAYANT
Entity Type:Individual
Prefix:
First Name:MAYURA
Middle Name:JAYANT
Last Name:RANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12388 COPENHAGEN CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2510
Mailing Address - Country:US
Mailing Address - Phone:941-718-3077
Mailing Address - Fax:
Practice Address - Street 1:10701 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6904
Practice Address - Country:US
Practice Address - Phone:703-273-7705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002149224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant