Provider Demographics
NPI:1023377538
Name:COOPER, KELLY L (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT
Mailing Address - Street 2:STE 203
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1672
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:703-239-2301
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-751-1008
Practice Address - Fax:703-751-1118
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2305207085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2307000967OtherDIRECT ACCESS CERTIFICATION
VAK949 - 0031OtherCAREFIRST