Provider Demographics
NPI:1326522871
Name:BRIGHAM, ELLEN (ATR-BC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BRIGHAM
Suffix:
Gender:F
Credentials:ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14464 GLENCREST CIR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-4131
Mailing Address - Country:US
Mailing Address - Phone:703-309-4363
Mailing Address - Fax:
Practice Address - Street 1:11230 WAPLES MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6087
Practice Address - Country:US
Practice Address - Phone:703-309-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA18-076221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist