Provider Demographics
NPI:1356128045
Name:GWOREK, KEITH DOUGLAS (OTD, OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DOUGLAS
Last Name:GWOREK
Suffix:
Gender:M
Credentials:OTD, OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:
Practice Address - Street 1:7650 E PARHAM RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4376
Practice Address - Country:US
Practice Address - Phone:804-915-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009154225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand