Provider Demographics
NPI:1104482959
Name:PRIBYL, KAITLYN S (PTA)
Entity type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:S
Last Name:PRIBYL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 FREEDOM BLVD APT C3
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6186
Mailing Address - Country:US
Mailing Address - Phone:906-250-4868
Mailing Address - Fax:
Practice Address - Street 1:880 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2815
Practice Address - Country:US
Practice Address - Phone:803-606-5573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3828225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant