Provider Demographics
NPI:1669141040
Name:BATHALON, ANDRE (PT)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:BATHALON
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 1:2727 MERRILEE DR APT 335
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4452
Mailing Address - Country:US
Mailing Address - Phone:571-373-2544
Mailing Address - Fax:
Practice Address - Street 1:2727 MERRILEE DR APT 335
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4452
Practice Address - Country:US
Practice Address - Phone:571-373-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist