Provider Demographics
NPI:1578557856
Name:PETZ, BRIAN ANDREW (ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ANDREW
Last Name:PETZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43240 CARDSTON PL
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-6459
Mailing Address - Country:US
Mailing Address - Phone:703-777-8213
Mailing Address - Fax:703-742-8952
Practice Address - Street 1:13039 WORLDGATE DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4374
Practice Address - Country:US
Practice Address - Phone:703-742-8758
Practice Address - Fax:703-742-8952
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260007182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer