Provider Demographics
NPI:1417126020
Name:FEDEROVICH, ELISSA H (PT, NCS)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:H
Last Name:FEDEROVICH
Suffix:
Gender:F
Credentials:PT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3918 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1853
Mailing Address - Country:US
Mailing Address - Phone:703-642-9176
Mailing Address - Fax:
Practice Address - Street 1:5249 DUKE ST
Practice Address - Street 2:STE 203
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2926
Practice Address - Country:US
Practice Address - Phone:703-751-1733
Practice Address - Fax:703-370-7209
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052020262251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA003535N93Medicare PIN