Provider Demographics
NPI:1801146220
Name:KELLEY, AMANDA (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 LOYOLA AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1033
Mailing Address - Country:US
Mailing Address - Phone:703-370-0360
Mailing Address - Fax:
Practice Address - Street 1:4343 LOYOLA AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1033
Practice Address - Country:US
Practice Address - Phone:703-370-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003925225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist