Healthcare Provider Details

I. General information

NPI: 1316630189
Provider Name (Legal Business Name): KATHRYN PROFFITT KEPHART PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE PROFFITT PT

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 LASKIN RD STE 706
VIRGINIA BEACH VA
23451-7504
US

IV. Provider business mailing address

PO BOX 412307
BOSTON MA
02241-2307
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-0052
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305215700
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: