Provider Demographics
NPI:1891349569
Name:TAVOLACCI, PHILLIP (MSPT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:TAVOLACCI
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4823
Mailing Address - Country:US
Mailing Address - Phone:301-652-2522
Mailing Address - Fax:
Practice Address - Street 1:407 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4823
Practice Address - Country:US
Practice Address - Phone:301-652-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist