Provider Demographics
NPI:1598643769
Name:ESMAEILI, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ESMAEILI
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 1:11147 BYRD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5364
Mailing Address - Country:US
Mailing Address - Phone:571-839-1892
Mailing Address - Fax:571-839-1892
Practice Address - Street 1:12436 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5258
Practice Address - Country:US
Practice Address - Phone:703-340-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305217373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist