Healthcare Provider Details

I. General information

NPI: 1114922556
Provider Name (Legal Business Name): KEVIN L. OUTWATER SR. PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 W MARKET ST STE 300
FAIRLAWN OH
44333-4202
US

IV. Provider business mailing address

2660 W MARKET ST STE 300
FAIRLAWN OH
44333-4206
US

V. Phone/Fax

Practice location:
  • Phone: 330-869-2635
  • Fax: 330-869-8315
Mailing address:
  • Phone: 330-869-2635
  • Fax: 330-869-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-04320
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: