Provider Demographics
NPI:1962476804
Name:IVESON, BRIAN D (DSCPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:IVESON
Suffix:
Gender:M
Credentials:DSCPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 CATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:QUANTICO
Mailing Address - State:VA
Mailing Address - Zip Code:22134-5109
Mailing Address - Country:US
Mailing Address - Phone:703-784-3205
Mailing Address - Fax:
Practice Address - Street 1:3259 CATLIN AVE
Practice Address - Street 2:
Practice Address - City:QUANTICO
Practice Address - State:VA
Practice Address - Zip Code:22134-5109
Practice Address - Country:US
Practice Address - Phone:703-784-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist