Basic Information
| Provider Information | |||||||||
| NPI: | 1073819942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEPHART | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5436 RICCI ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763025124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406426412 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 1ST ST | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764503603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405498787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2063841 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.