Provider Demographics
NPI:1023488558
Name:KAGAWA, KEISUKE (ATC)
Entity type:Individual
Prefix:
First Name:KEISUKE
Middle Name:
Last Name:KAGAWA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 CLAIRMONT RD NE
Mailing Address - Street 2:APARTMENT C
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2627
Mailing Address - Country:US
Mailing Address - Phone:304-685-3699
Mailing Address - Fax:
Practice Address - Street 1:2803 CLAIRMONT RD NE
Practice Address - Street 2:APARTMENT C
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2627
Practice Address - Country:US
Practice Address - Phone:304-685-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0027072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer