Provider Demographics
NPI:1972939338
Name:TAYLOR, KELLY BAKER (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BAKER
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BAKER
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:9455 LORTON MARKET ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1962
Mailing Address - Country:US
Mailing Address - Phone:703-647-3120
Mailing Address - Fax:703-339-6352
Practice Address - Street 1:9455 LORTON MARKET ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1962
Practice Address - Country:US
Practice Address - Phone:703-647-3120
Practice Address - Fax:703-339-6352
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60378525225100000X
VA2305208936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist