Provider Demographics
NPI:1497142780
Name:MARVIN, AMANDA (ATC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MARVIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 WAPLES MILL RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6078
Mailing Address - Country:US
Mailing Address - Phone:703-810-5286
Mailing Address - Fax:
Practice Address - Street 1:11240 WAPLES MILL RD
Practice Address - Street 2:SUITE 403
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6078
Practice Address - Country:US
Practice Address - Phone:703-810-5286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer