Provider Demographics
NPI:1457028490
Name:BLAINE, ADAM (DPT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BLAINE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 4TH ST N APT 108
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-3006
Mailing Address - Country:US
Mailing Address - Phone:304-923-2694
Mailing Address - Fax:
Practice Address - Street 1:225 REINEKERS LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2856
Practice Address - Country:US
Practice Address - Phone:703-672-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist