Provider Demographics
NPI:1104581727
Name:ABRAMS, SHALLESE
Entity type:Individual
Prefix:
First Name:SHALLESE
Middle Name:
Last Name:ABRAMS
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 1:8416 GRANITE LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2345
Mailing Address - Country:US
Mailing Address - Phone:702-538-4708
Mailing Address - Fax:
Practice Address - Street 1:1739 KIRBY RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4817
Practice Address - Country:US
Practice Address - Phone:703-506-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant