Provider Demographics
NPI:1770450124
Name:VAN, KEVIN DAT (DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAT
Last Name:VAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MANSELL RD STE H
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4800
Mailing Address - Country:US
Mailing Address - Phone:678-821-2170
Mailing Address - Fax:
Practice Address - Street 1:875 MANSELL RD STE H
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4800
Practice Address - Country:US
Practice Address - Phone:678-821-2170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305217444225100000X
GACP050485T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist