Provider Demographics
NPI:1710929021
Name:KEPHART, MARISA (PT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:KEPHART
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 1:270 SUSQUEHANNA VALLEY MALL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9115
Mailing Address - Country:US
Mailing Address - Phone:570-743-1703
Mailing Address - Fax:570-743-1728
Practice Address - Street 1:75 E DERRY RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2705
Practice Address - Country:US
Practice Address - Phone:717-298-6245
Practice Address - Fax:717-298-7774
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011667L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018567660009Medicaid