Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 0119006625 | VA |
NPI | 1255717575 |
---|---|
Provider Name | Chara Civitello |
First Address | Burke, VA 22015-4640 |
Second Address | Burke, VA 22015 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2015 |
Last Update Date | 10/08/2015 |