Provider Demographics
NPI:1225643067
Name:THOMAS, KYLE CHACKO (OTR/L)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CHACKO
Last Name:THOMAS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42090 BARRYMOORE PL
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6438
Mailing Address - Country:US
Mailing Address - Phone:443-986-4300
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST STE 417
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7174
Practice Address - Country:US
Practice Address - Phone:703-717-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008753225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty