Basic Information
| Provider Information | |||||||||
| NPI: | 1598293417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTLEY | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERS | ||||||||
| OtherFirstName: | KAITLIN | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 170 TAYLOR STATION RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432134491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145457900 | ||||||||
| FaxNumber: | 6145457901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4611 TRUEMAN BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430262485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143400683 | ||||||||
| FaxNumber: | 6143450734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 016833 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 016833 | 01 | OH | PT | OTHER |