Provider Demographics
NPI:1225802101
Name:TEA, TIFFANY NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:TEA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1013
Mailing Address - Country:US
Mailing Address - Phone:703-635-5614
Mailing Address - Fax:
Practice Address - Street 1:1561 POTOMAC GREENS DR UNIT 1A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-6255
Practice Address - Country:US
Practice Address - Phone:703-717-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist