Provider Demographics
NPI:1730962028
Name:KELLERMEYER, KAITLYN RAE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:RAE
Last Name:KELLERMEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 AVENIR PL APT 4310
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-7181
Mailing Address - Country:US
Mailing Address - Phone:214-616-5755
Mailing Address - Fax:
Practice Address - Street 1:10521 ROSEHAVEN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2876
Practice Address - Country:US
Practice Address - Phone:703-352-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical