Provider Demographics
NPI:1215103817
Name:AUSTIN TUCK, KELLY LEIGH (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEIGH
Last Name:AUSTIN TUCK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:LEIGH
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2617 PRESTON MILL RD
Mailing Address - Street 2:
Mailing Address - City:HUDDLESTON
Mailing Address - State:VA
Mailing Address - Zip Code:24104-4113
Mailing Address - Country:US
Mailing Address - Phone:540-297-8301
Mailing Address - Fax:
Practice Address - Street 1:1317 LOLA AVE
Practice Address - Street 2:
Practice Address - City:ALTAVISTA
Practice Address - State:VA
Practice Address - Zip Code:24517-1352
Practice Address - Country:US
Practice Address - Phone:434-369-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004124225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist