Provider Demographics
NPI:1841805942
Name:TIRSO, CARLO
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
Last Name:TIRSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 QUEEN ANNE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-1831
Mailing Address - Country:US
Mailing Address - Phone:703-402-0816
Mailing Address - Fax:
Practice Address - Street 1:6035 BURKE CENTRE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3750
Practice Address - Country:US
Practice Address - Phone:703-978-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305213664OtherVIRGINIA DEPARTMENT OF HEALTH/ PHYSICAL THERAPY LICENSE