Provider Demographics
NPI:1821115312
Name:KIETZER, KELLEE S (LPTA)
Entity Type:Individual
Prefix:MS
First Name:KELLEE
Middle Name:S
Last Name:KIETZER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10340 LAUNCH CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4263
Mailing Address - Country:US
Mailing Address - Phone:703-973-3068
Mailing Address - Fax:
Practice Address - Street 1:8575 RIXLEW LANE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109
Practice Address - Country:US
Practice Address - Phone:703-257-9770
Practice Address - Fax:703-257-2937
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602077225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant