Healthcare Provider Details

I. General information

NPI: 1356128045
Provider Name (Legal Business Name): KEITH DOUGLAS GWOREK OTD, OTR/L, CLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7650 E PARHAM RD STE 100
RICHMOND VA
23294-4376
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-915-1910
  • Fax:
Mailing address:
  • Phone: 804-915-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number0119009154
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: