Provider Demographics
NPI:1134760564
Name:TAVAKOLI, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 MISSION SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1113
Mailing Address - Country:US
Mailing Address - Phone:757-334-4514
Mailing Address - Fax:
Practice Address - Street 1:3046 MISSION SQUARE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1113
Practice Address - Country:US
Practice Address - Phone:757-334-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202216060183500000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No183500000XPharmacy Service ProvidersPharmacist