Provider Demographics
NPI:1225337223
Name:BOLES, TRACY E (DPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:E
Last Name:BOLES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 SUNRISE VALLEY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5309
Mailing Address - Country:US
Mailing Address - Phone:703-709-1116
Mailing Address - Fax:703-709-5134
Practice Address - Street 1:11800 SUNRISE VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5309
Practice Address - Country:US
Practice Address - Phone:703-709-1116
Practice Address - Fax:703-709-5134
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204913225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist