Provider Demographics
NPI:1306211347
Name:WADSWORTH, KELLIE N (DPT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:N
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:RAMIREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:10716 RICHMOND HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2645
Mailing Address - Country:US
Mailing Address - Phone:703-892-6500
Mailing Address - Fax:703-521-3415
Practice Address - Street 1:10716 RICHMOND HWY STE 103
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-2645
Practice Address - Country:US
Practice Address - Phone:703-892-6500
Practice Address - Fax:703-521-3415
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist