Provider Demographics
NPI:1821062209
Name:THRELFALL, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:THRELFALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 IRVING ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3017
Mailing Address - Country:US
Mailing Address - Phone:301-540-6140
Mailing Address - Fax:
Practice Address - Street 1:12825 MINNIEVILLE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3601
Practice Address - Country:US
Practice Address - Phone:703-971-3701
Practice Address - Fax:703-647-3126
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2831225100000X
VA2305206415225100000X
GA010474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120150AMedicaid
NH08Y004741NH01OtherANTHEM
NH30392274Medicaid
GA00800698OtherAMERIGROUP
GA00800698OtherAMERIGROUP
NHRE7194Medicare ID - Type Unspecified