Provider Demographics
NPI:1770943946
Name:WILLIAMSON, KAHLA MARIE
Entity type:Individual
Prefix:
First Name:KAHLA
Middle Name:MARIE
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAHLA
Other - Middle Name:M
Other - Last Name:HACKENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:2813 INDUSTRIAL PARK RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-9078
Practice Address - Country:US
Practice Address - Phone:717-436-6042
Practice Address - Fax:717-436-6264
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030869050001Medicaid