Provider Demographics
NPI:1588819262
Name:DELFAVERO, MICHELLE LEE (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:DELFAVERO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 PENDER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0985
Mailing Address - Country:US
Mailing Address - Phone:703-255-2339
Mailing Address - Fax:703-255-2402
Practice Address - Street 1:6273 FRANCONIA RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2510
Practice Address - Country:US
Practice Address - Phone:703-719-9460
Practice Address - Fax:703-719-9461
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LU60OtherBCBS OF MARYLAND
7914198OtherAETNA
T208OtherBLUECHOICE GHMSI
7914198OtherAETNA