Provider Demographics
NPI:1316630189
Name:KEPHART, KATHRYN PROFFITT (PT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:PROFFITT
Last Name:KEPHART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:PROFFITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 412307
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2307
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:1628 LASKIN RD STE 706
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-7504
Practice Address - Country:US
Practice Address - Phone:757-481-0052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
VA2305215700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist