Provider Demographics
NPI:1720219546
Name:RANDALL, ELISHA (DPT)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELISHA
Other - Middle Name:MARIE
Other - Last Name:WHITNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1501 DUKE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3468
Mailing Address - Country:US
Mailing Address - Phone:703-535-5491
Mailing Address - Fax:703-535-5494
Practice Address - Street 1:1501 DUKE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3468
Practice Address - Country:US
Practice Address - Phone:703-535-5491
Practice Address - Fax:703-535-5494
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT871042225100000X
VA2305206648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist