Provider Demographics
NPI:1891982401
Name:KWON, TAE (PT)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 N GLEBE RD
Mailing Address - Street 2:814
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 S CARLIN SPRINGS RD
Practice Address - Street 2:505
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1064
Practice Address - Country:US
Practice Address - Phone:703-820-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist