Healthcare Provider Details

I. General information

NPI: 1740702786
Provider Name (Legal Business Name): KAITLYN NICOLE KALISZ OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 STAFFORD AVE
STAFFORD VA
22554-7246
US

IV. Provider business mailing address

43 MUSTER DR
STAFFORD VA
22554-8503
US

V. Phone/Fax

Practice location:
  • Phone: 540-658-6000
  • Fax:
Mailing address:
  • Phone: 540-272-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119007379
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: