Provider Demographics
NPI:1356822464
Name:BLACK, KELSEY ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 HARPERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1085
Mailing Address - Country:US
Mailing Address - Phone:757-223-1668
Mailing Address - Fax:757-591-0024
Practice Address - Street 1:955 HARPERSVILLE RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1085
Practice Address - Country:US
Practice Address - Phone:757-223-1668
Practice Address - Fax:757-591-0024
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119-007731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist