Provider Demographics
NPI:1962617084
Name:NEWHOUSE, TISA L (PTA)
Entity type:Individual
Prefix:
First Name:TISA
Middle Name:L
Last Name:NEWHOUSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14123 WELLMAN CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-7003
Mailing Address - Country:US
Mailing Address - Phone:703-794-8220
Mailing Address - Fax:
Practice Address - Street 1:12191 CLIPPER DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2237
Practice Address - Country:US
Practice Address - Phone:703-496-3486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001507225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant