Provider Demographics
NPI:1508867532
Name:PETIT, KEVIN S (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:PETIT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 NEFF AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3495
Mailing Address - Country:US
Mailing Address - Phone:540-434-1664
Mailing Address - Fax:540-437-0052
Practice Address - Street 1:313 NEFF AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-3495
Practice Address - Country:US
Practice Address - Phone:540-434-1664
Practice Address - Fax:540-437-0052
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
103077OtherANTHEM
Q11540Medicare UPIN
VA004077H96Medicare ID - Type Unspecified
VA0636510001Medicare NSC