Provider Demographics
NPI:1780453308
Name:STREET, KONNER SLOANE (DPT)
Entity type:Individual
Prefix:
First Name:KONNER
Middle Name:SLOANE
Last Name:STREET
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KONNER
Other - Middle Name:SLOANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:243 RIDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1647
Mailing Address - Country:US
Mailing Address - Phone:423-418-2202
Mailing Address - Fax:
Practice Address - Street 1:71 ORPHANAGE RD
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-3006
Practice Address - Country:US
Practice Address - Phone:859-331-0880
Practice Address - Fax:855-719-0501
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0089952251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics