Healthcare Provider Details

I. General information

NPI: 1790135549
Provider Name (Legal Business Name): KELLEY WILLIS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14900 BOGLE DR SUITE 200
CHANTILLY VA
20151-1756
US

IV. Provider business mailing address

14900 BOGLE DR SUITE 200
CHANTILLY VA
20151-1756
US

V. Phone/Fax

Practice location:
  • Phone: 703-817-9890
  • Fax: 703-817-9860
Mailing address:
  • Phone: 703-817-9890
  • Fax: 703-817-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: