Provider Demographics
NPI:1902572209
Name:BEAUCHAMP, KYLIE RAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:RAE
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 OLD WEST BROAD ST BLDG 2-200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2887
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:
Practice Address - Street 1:705 BREEDLOVE DR STE 200
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2080
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
15630687OtherCAQH NUMBER