Healthcare Provider Details

I. General information

NPI: 1255889796
Provider Name (Legal Business Name): KELSEY JO BARBOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15531 DIASCUND POINTE TRL
LANEXA VA
23089-6032
US

IV. Provider business mailing address

15531 DIASCUND POINTE TRL
LANEXA VA
23089-6032
US

V. Phone/Fax

Practice location:
  • Phone: 804-699-0090
  • Fax:
Mailing address:
  • Phone: 804-699-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131001626
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: