Provider Demographics
NPI:1255333944
Name:ALTMAN, KERRY PAUL (PHD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:PAUL
Last Name:ALTMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 OLD LEE HWY
Mailing Address - Street 2:SUITE 63 D
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2428
Mailing Address - Country:US
Mailing Address - Phone:703-691-1571
Mailing Address - Fax:703-691-2103
Practice Address - Street 1:3923 OLD LEE HWY
Practice Address - Street 2:SUITE 63 D
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2428
Practice Address - Country:US
Practice Address - Phone:703-691-1571
Practice Address - Fax:703-691-2103
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187342Medicare ID - Type Unspecified