Provider Demographics
NPI:1639412505
Name:DIAZ-TAVERA, CAROLINA (PT)
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:
Last Name:DIAZ-TAVERA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MONROE ST
Mailing Address - Street 2:SUITE 1207
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2421
Mailing Address - Country:US
Mailing Address - Phone:301-838-2040
Mailing Address - Fax:
Practice Address - Street 1:2500 N VAN DORN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1626
Practice Address - Country:US
Practice Address - Phone:703-933-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist