Provider Demographics
NPI:1316981228
Name:BRADY, SUSAN SUMMERILL (MPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SUMMERILL
Last Name:BRADY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NALLS DAIRY COURT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066
Mailing Address - Country:US
Mailing Address - Phone:703-948-9176
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-556-4424
Practice Address - Fax:703-556-4435
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004781225100000X
002606133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist