Healthcare Provider Details

I. General information

NPI: 1497082481
Provider Name (Legal Business Name): MARILYN A KEELER LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 HERITAGE VILLAGE PLZ
GAINESVILLE VA
20155-3078
US

IV. Provider business mailing address

7501 HERITAGE VILLAGE PLZ
GAINESVILLE VA
20155-3078
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-6100
  • Fax: 571-248-6455
Mailing address:
  • Phone: 571-248-6100
  • Fax: 571-248-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306000134
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: