Provider Demographics
NPI:1326669615
Name:STADLBAUER, KEVIN AARON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:AARON
Last Name:STADLBAUER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:590 441 HISTORIC HWY N STE E
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4561
Practice Address - Country:US
Practice Address - Phone:706-754-6611
Practice Address - Fax:706-754-5834
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT014547OtherPROFESSIONAL LICENSING BOARD