Provider Demographics
NPI:1578997144
Name:PEAVEY, KATHLEEN JO (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JO
Last Name:PEAVEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:JO
Other - Last Name:ORESKOVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,DPT
Mailing Address - Street 1:217 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-1915
Mailing Address - Country:US
Mailing Address - Phone:317-902-6244
Mailing Address - Fax:
Practice Address - Street 1:511 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4890
Practice Address - Country:US
Practice Address - Phone:864-757-9918
Practice Address - Fax:864-757-9921
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC70922251P0200X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3018Medicaid