Provider Demographics
NPI:1396230405
Name:KELLEY, KATHERINE (COTA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12873 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LOVETTSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20180-2807
Mailing Address - Country:US
Mailing Address - Phone:540-687-1636
Mailing Address - Fax:
Practice Address - Street 1:150 ELDEN ST STE 270
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4845
Practice Address - Country:US
Practice Address - Phone:703-536-1817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA404009224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant