Provider Demographics
NPI:1215236690
Name:INTEGRATIVE PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:INTEGRATIVE PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, PT
Authorized Official - Phone:703-786-8827
Mailing Address - Street 1:512 HERNDON PARKWAY, SUITE F
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-786-8827
Mailing Address - Fax:
Practice Address - Street 1:512 HERNDON PKWY STE F
Practice Address - Street 2:SUITE 120
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5244
Practice Address - Country:US
Practice Address - Phone:786-882-7786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PHYSICAL THERAPY AND WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-24
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2307000500261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy