Provider Demographics
NPI:1962407411
Name:FATHALIKHANI, HADI (PT)
Entity type:Individual
Prefix:
First Name:HADI
Middle Name:
Last Name:FATHALIKHANI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14014 SULLYFIELD CIR
Mailing Address - Street 2:STE B
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1689
Mailing Address - Country:US
Mailing Address - Phone:703-263-2020
Mailing Address - Fax:703-263-2015
Practice Address - Street 1:12546 DILLINGHAM SQ
Practice Address - Street 2:# 101
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5259
Practice Address - Country:US
Practice Address - Phone:703-730-6969
Practice Address - Fax:703-730-1169
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA519289OtherMAMSI PROVIDER NUMBER
VAS427-0001OtherCAREFIRST BCBS PROVIDER #
VA265661OtherANTHEM PROVIDER NUMBER