Provider Demographics
NPI:1750868253
Name:MIRELES, MARLENE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:MIRELES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:MORALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12816 VALLEYHILL ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6419
Mailing Address - Country:US
Mailing Address - Phone:703-718-5909
Mailing Address - Fax:
Practice Address - Street 1:12816 VALLEYHILL ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6419
Practice Address - Country:US
Practice Address - Phone:703-718-5909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1192610225100000X
225100000X
VA2305212097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist