Healthcare Provider Details

I. General information

NPI: 1700423431
Provider Name (Legal Business Name): TAMARA ELISA KEFEYAN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 CHESTNUT STATION CT
LOUISVILLE KY
40299-6395
US

IV. Provider business mailing address

98 FARNHAM ST
BELMONT MA
02478-3178
US

V. Phone/Fax

Practice location:
  • Phone: 800-335-1060
  • Fax:
Mailing address:
  • Phone: 617-775-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15942
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: