Provider Demographics
NPI:1336622257
Name:PROGRESSIVE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:PROGRESSIVE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:703-606-6213
Mailing Address - Street 1:150 S WASHINGTON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-2921
Mailing Address - Country:US
Mailing Address - Phone:703-606-6213
Mailing Address - Fax:703-496-4779
Practice Address - Street 1:150 S. WASHINGTON ST.
Practice Address - Street 2:#203
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22124
Practice Address - Country:US
Practice Address - Phone:703-606-6213
Practice Address - Fax:703-496-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01050051062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty