Provider Demographics
NPI:1346458494
Name:DIBELLA, CAROLYN GAYLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:GAYLE
Last Name:DIBELLA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 DOVEVILLE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1446
Mailing Address - Country:US
Mailing Address - Phone:571-235-1613
Mailing Address - Fax:
Practice Address - Street 1:2579 JOHN MILTON DR
Practice Address - Street 2:SUITE 120
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-2563
Practice Address - Country:US
Practice Address - Phone:703-860-2346
Practice Address - Fax:703-860-2348
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601947225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant