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General NPI Number Information
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NPI Number | 1073936407
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Entity Type | Organization
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Legal Business Name | KINESIO PHYSICAL THERAPY AND SPORTS REHABILITATION, LLC
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Dates
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Enumeration Date | 01/21/2014
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Last Update Date | 01/21/2014
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Provider Practice Location Address
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Address Line | 821 W BENFIELD RD SUITE 7
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City | SEVERNA PARK
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State | MD
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Zip | 21146-2220
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Country | US
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Telephone | 443-994-2640
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Fax |
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Provider Business Mailing Address
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Address Line | 418 RED BIRCH RD
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City | MILLERSVILLE
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State | MD
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Zip | 21108-1414
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | FAITH K HAGERTY
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Credential | P.T.
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Telephone | 410-987-5746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 17817
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License Number State | MD
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