Healthcare Provider Details

I. General information

NPI: 1245786797
Provider Name (Legal Business Name): FOOTPRINTS PEDIATRIC THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PINEHILLS DR
HATTIESBURG MS
39402-3317
US

IV. Provider business mailing address

135 PINEHILLS DR
HATTIESBURG MS
39402-3317
US

V. Phone/Fax

Practice location:
  • Phone: 864-293-3281
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT6066
License Number StateMS

VIII. Authorized Official

Name: VIRGINIA C. KOLVITES
Title or Position: OWNER
Credential: DPT
Phone: 864-293-3281