Provider Demographics
NPI:1215927454
Name:PENDERGRASS, TIMOTHY (PT, DSC, ATC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:PT, DSC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5448 EDSALL RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-2673
Mailing Address - Country:US
Mailing Address - Phone:301-318-6217
Mailing Address - Fax:
Practice Address - Street 1:BLDG 0-1900
Practice Address - Street 2:LAMONT ROAD
Practice Address - City:FT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:23807
Practice Address - Country:US
Practice Address - Phone:910-643-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist