Provider Demographics
NPI:1669656443
Name:KASYCH, LAURA ANN (PT)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:KASYCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24532 DEER TRACE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2111
Mailing Address - Country:US
Mailing Address - Phone:904-495-1194
Mailing Address - Fax:
Practice Address - Street 1:24532 DEER TRACE DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-2111
Practice Address - Country:US
Practice Address - Phone:904-495-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 26668225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419800000Medicaid