Provider Demographics
NPI:1285414540
Name:FAERBER, KEALAN WINTERS (PTA)
Entity type:Individual
Prefix:
First Name:KEALAN
Middle Name:WINTERS
Last Name:FAERBER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KEALAN
Other - Middle Name:WINTERS
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7508
Mailing Address - Country:US
Mailing Address - Phone:401-684-4686
Mailing Address - Fax:
Practice Address - Street 1:100 ROMANO VINEYARD WAY STE 120
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-8428
Practice Address - Country:US
Practice Address - Phone:401-268-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA00724225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant