Provider Demographics
NPI:1215591714
Name:CARESTIA, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CARESTIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N GLEBE RD STE 410
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-5931
Mailing Address - Country:US
Mailing Address - Phone:571-414-6930
Mailing Address - Fax:571-414-6941
Practice Address - Street 1:1005 N GLEBE RD STE 410
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-5931
Practice Address - Country:US
Practice Address - Phone:571-414-6930
Practice Address - Fax:571-414-6941
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2020-11-13
Deactivation Date:2019-08-14
Deactivation Code:
Reactivation Date:2019-08-21
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA2305213094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program