Provider Demographics
NPI:1639739303
Name:KUCHINOV, KELLEY
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:
Last Name:KUCHINOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20120 BANDON DUNES CT
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7019
Mailing Address - Country:US
Mailing Address - Phone:732-995-2637
Mailing Address - Fax:
Practice Address - Street 1:11250 ROGER BACON DR STE 301
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5219
Practice Address - Country:US
Practice Address - Phone:209-789-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist