Provider Demographics
NPI:1073936407
Name:KINESIO PHYSICAL THERAPY AND SPORTS REHABILITATION, LLC
Entity Type:Organization
Organization Name:KINESIO PHYSICAL THERAPY AND SPORTS REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-987-5746
Mailing Address - Street 1:418 RED BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 W BENFIELD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2220
Practice Address - Country:US
Practice Address - Phone:443-994-2640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578634077OtherMEDICARE NPI INDIVIDUAL
320171OtherMEDICARE IDENTIFICATION NUMBER