Provider Demographics
NPI:1275572661
Name:PENNOCK, KATHLEEN (MS, PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:TAIBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PT
Mailing Address - Street 1:10128 W BROAD ST BLDG III
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6761
Mailing Address - Country:US
Mailing Address - Phone:804-217-9210
Mailing Address - Fax:804-217-9213
Practice Address - Street 1:10128 W BROAD ST BLDG III
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6761
Practice Address - Country:US
Practice Address - Phone:804-217-9210
Practice Address - Fax:804-217-9213
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
23052026952251X0800X
VA2305202695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA540885859OtherCORVEL
VA258462OtherSOUTHERN HEALTH
VA98999OtherOPTIMA HEALTH
VA540885859OtherFOCUS
VA540885859OtherVIRGINIA HEALTH NETWORK
VA540885859OtherMULTIPLAN
VA540885859OtherPRIVATE HEALTHCARE SYSTEM
VA540885859OtherCOMPMANAGEMENT
VA010206626Medicaid
VA192289OtherANTHEM HANOVER PT
VA540885859OtherC&O EMPLOYEE'S HEALTHCARE
VA540885859OtherFIRST HEALTH/CCN