Provider Demographics
NPI:1457647836
Name:BOTTORFF, STACEY M (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:BOTTORFF
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 LOGAN CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9409K OLD BURKE LAKE RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3127
Practice Address - Country:US
Practice Address - Phone:703-425-1800
Practice Address - Fax:434-220-0072
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26503225100000X
VA2305207963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist