Provider Demographics
NPI:1669033197
Name:MYRICK, KIEIFI A (OT)
Entity Type:Individual
Prefix:
First Name:KIEIFI
Middle Name:A
Last Name:MYRICK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT STE 203
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1673
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:
Practice Address - Street 1:102 ELDEN ST STE 12
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4839
Practice Address - Country:US
Practice Address - Phone:703-587-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008122225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist