Basic Information
Provider Information | |||||||||
NPI: | 1346673860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KEAFER DEROUSSE | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KEAFER | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 73 NEWTON RD | ||||||||
Address2: | STE 101 | ||||||||
City: | PLAISTOW | ||||||||
State: | NH | ||||||||
PostalCode: | 038652424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9783887272 | ||||||||
FaxNumber: | 9783887373 | ||||||||
Practice Location | |||||||||
Address1: | 881 LAFAYETTE RD | ||||||||
Address2: | UNIT K | ||||||||
City: | HAMPTON | ||||||||
State: | NH | ||||||||
PostalCode: | 038421242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6039292880 | ||||||||
FaxNumber: | 6039291296 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2013 | ||||||||
LastUpdateDate: | 08/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4114 | NH | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.