Provider Demographics
NPI:1619365798
Name:SPICE, GINGER (PTA)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:SPICE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14104 ESSEX DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-2519
Mailing Address - Country:US
Mailing Address - Phone:571-931-7420
Mailing Address - Fax:877-771-3419
Practice Address - Street 1:17775 MAIN ST
Practice Address - Street 2:STE 104
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-2491
Practice Address - Country:US
Practice Address - Phone:571-931-7420
Practice Address - Fax:877-771-3419
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2306601285225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant