Provider Demographics
NPI:1942379094
Name:WOOTTEN, TERRI LYNN BOGLE (VATL,ATC)
Entity Type:Individual
Prefix:MRS
First Name:TERRI LYNN
Middle Name:BOGLE
Last Name:WOOTTEN
Suffix:
Gender:F
Credentials:VATL,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10803 PINE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2821
Mailing Address - Country:US
Mailing Address - Phone:703-279-1554
Mailing Address - Fax:703-279-1554
Practice Address - Street 1:6600 LITTLE FALLS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22213-1211
Practice Address - Country:US
Practice Address - Phone:703-538-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0126-0000012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer