Healthcare Provider Details

I. General information

NPI: 1275572661
Provider Name (Legal Business Name): KATHLEEN PENNOCK MS, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN TAIBE MS, PT

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10128 W BROAD ST BLDG III
GLEN ALLEN VA
23060-6761
US

IV. Provider business mailing address

10128 W BROAD ST BLDG III
GLEN ALLEN VA
23060-6761
US

V. Phone/Fax

Practice location:
  • Phone: 804-217-9210
  • Fax: 804-217-9213
Mailing address:
  • Phone: 804-217-9210
  • Fax: 804-217-9213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305202695
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305202695
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: