Provider Demographics
NPI:1134727357
Name:SUTPHIN, ELENA IGOREVNA (PTA)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:IGOREVNA
Last Name:SUTPHIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35332 QUAIL MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-3116
Mailing Address - Country:US
Mailing Address - Phone:929-272-6742
Mailing Address - Fax:
Practice Address - Street 1:1936 OPITZ BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3360
Practice Address - Country:US
Practice Address - Phone:540-841-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23066055322081P0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306605532OtherVA DEPARTMENT OF HEALTH PROFESSIONALS/BOARD OF PHYSICAL THERAPY