Provider Demographics
NPI:1558002790
Name:SURAFEL, KIDIST (COTA/L)
Entity Type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:SURAFEL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 WOODMIRE LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1301
Mailing Address - Country:US
Mailing Address - Phone:703-244-1191
Mailing Address - Fax:
Practice Address - Street 1:5148 WOODMIRE LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1301
Practice Address - Country:US
Practice Address - Phone:703-244-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-03
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOTA100000204225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist