Healthcare Provider Details

I. General information

NPI: 1528776101
Provider Name (Legal Business Name): KELLAN WRIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 SUNRISE VALLEY DR STE 100
RESTON VA
20191-3429
US

IV. Provider business mailing address

931 N AUGUSTA ST APT 3
STAUNTON VA
24401-3293
US

V. Phone/Fax

Practice location:
  • Phone: 646-941-7645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014534
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: