Provider Demographics
NPI:1164905329
Name:BACON, KATHLEEN (DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-5491
Mailing Address - Country:US
Mailing Address - Phone:401-529-4350
Mailing Address - Fax:
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-738-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist