Provider Demographics
NPI:1336880921
Name:PICHT, KEITH JOHN II (PTA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JOHN
Last Name:PICHT
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:232-387-2174
Mailing Address - Fax:
Practice Address - Street 1:1004 PROGRESS DR STE 100
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-6323
Practice Address - Country:US
Practice Address - Phone:913-351-3586
Practice Address - Fax:913-351-3939
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03959225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty