Provider Demographics
NPI:1407494990
Name:ACTIVE FOR LIFE PHYSICAL THERAPY
Entity type:Organization
Organization Name:ACTIVE FOR LIFE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MAUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:703-597-4358
Mailing Address - Street 1:511 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3314
Mailing Address - Country:US
Mailing Address - Phone:703-597-4358
Mailing Address - Fax:
Practice Address - Street 1:511 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3314
Practice Address - Country:US
Practice Address - Phone:703-249-9757
Practice Address - Fax:703-520-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty