Individual
PHONGPHAN ROACH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2980 CENTREVILLE RD, HERNDON, VA 20171-6254
(703) 994-4561
Mailing address
1912 VILLARIDGE DR UNIT B, RESTON, VA 20191-4830
(916) 450-1203
Taxonomy
Speciality
Code
Description
License number
State
225XP0019X
Physical Rehabilitation Occupational Therapist
Primary
0131001567
VA
Other
Enumeration date
10/09/2017
Last updated
10/09/2017
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