Basic Information
| Provider Information | |||||||||
| NPI: | 1346233863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AUGUSTINE | ||||||||
| FirstName: | CHRISTIE | ||||||||
| MiddleName: | KENNEDY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | CHRISTIE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | HC 6 BOX 6046 | ||||||||
| Address2: | |||||||||
| City: | HAWLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184289100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702265680 | ||||||||
| FaxNumber: | 5702265682 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 BRYNN MARR RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285467023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104789701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 05/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P19468 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT008630L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 819229 | 01 | 1ST PRIO-NOLIMITS | OTHER | AU1693421 | 01 | BLUE SHIELD | OTHER | PT00863OL | 01 | LIC # | OTHER | 842948 | 01 | MPN | OTHER | 9373970 | 01 | PHCS | OTHER | 819136 | 01 | 1ST PRIO-MOTION | OTHER |