Provider Demographics
NPI:1942556170
Name:COLEY, KYLIE RACHELLE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:RACHELLE
Last Name:COLEY
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 1:12001 TYGART LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-6120
Mailing Address - Country:US
Mailing Address - Phone:703-257-0356
Mailing Address - Fax:
Practice Address - Street 1:12001 TYGART LAKE DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-6120
Practice Address - Country:US
Practice Address - Phone:703-257-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107993235Z00000X
VA2202008731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX149984001Medicaid