Provider Demographics
NPI:1881302081
Name:KEPHART, DILLON (DPT)
Entity type:Individual
Prefix:
First Name:DILLON
Middle Name:
Last Name:KEPHART
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:PO BOX 412307
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2307
Mailing Address - Country:US
Mailing Address - Phone:814-571-0192
Mailing Address - Fax:
Practice Address - Street 1:1301 CEDAR RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-7105
Practice Address - Country:US
Practice Address - Phone:757-512-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305215000OtherPHYSICAL THERAPY LICENSE