Provider Demographics
NPI:1801967203
Name:BRAXTON-COLWELL, TERI DIANE (PT)
Entity type:Individual
Prefix:MRS
First Name:TERI
Middle Name:DIANE
Last Name:BRAXTON-COLWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TERI
Other - Middle Name:DIANE
Other - Last Name:BRAXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:20496 BLUE HERON TER
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6573
Mailing Address - Country:US
Mailing Address - Phone:703-450-1919
Mailing Address - Fax:
Practice Address - Street 1:20535 EARHART PL
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-3581
Practice Address - Country:US
Practice Address - Phone:703-404-5223
Practice Address - Fax:703-404-5206
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist