Provider Demographics
NPI:1972823607
Name:SLATTERY, IAN MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:SLATTERY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-1769
Mailing Address - Country:US
Mailing Address - Phone:540-687-8181
Mailing Address - Fax:540-687-8256
Practice Address - Street 1:13039 WORLDGATE DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4374
Practice Address - Country:US
Practice Address - Phone:703-689-3164
Practice Address - Fax:703-689-3167
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist