Provider Demographics
NPI:1720804339
Name:BOLADE, MAMTA U (PT)
Entity type:Individual
Prefix:MRS
First Name:MAMTA
Middle Name:U
Last Name:BOLADE
Suffix:
Gender:F
Credentials:PT
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Mailing Address - Street 1:25476 HARTLAND ORCHARD TER
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIDING
Mailing Address - State:VA
Mailing Address - Zip Code:20152-3268
Mailing Address - Country:US
Mailing Address - Phone:202-487-0563
Mailing Address - Fax:
Practice Address - Street 1:24790 MEADOWS FARMS CT
Practice Address - Street 2:
Practice Address - City:SOUTH RIDING
Practice Address - State:VA
Practice Address - Zip Code:20152-3000
Practice Address - Country:US
Practice Address - Phone:703-372-4445
Practice Address - Fax:703-957-3365
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA2305216674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant