Provider Demographics
NPI:1356145700
Name:BUSSELL, CARLY NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:BUSSELL
Suffix:
Gender:
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12065 GREYWING SQ APT B1
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1866
Mailing Address - Country:US
Mailing Address - Phone:571-253-1842
Mailing Address - Fax:
Practice Address - Street 1:21750 RED RUM DR STE 117
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5867
Practice Address - Country:US
Practice Address - Phone:703-574-2989
Practice Address - Fax:703-574-2941
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002880224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant