Provider Demographics
NPI:1306375282
Name:KOPPELLA, SUSMITA (PT)
Entity Type:Individual
Prefix:
First Name:SUSMITA
Middle Name:
Last Name:KOPPELLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21475 RIDGETOP CIR
Mailing Address - Street 2:STE 150
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6580
Mailing Address - Country:US
Mailing Address - Phone:347-602-2450
Mailing Address - Fax:
Practice Address - Street 1:21475 RIDGETOP CIR STE 260
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8580
Practice Address - Country:US
Practice Address - Phone:703-433-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210965225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist