1083911861 NPI number — KATHERINE THERESA DELCONTIVO MA, ATC, LAT

Table of content: KATHERINE THERESA DELCONTIVO MA, ATC, LAT (NPI 1083911861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083911861 NPI number — KATHERINE THERESA DELCONTIVO MA, ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELCONTIVO
Provider First Name:
KATHERINE
Provider Middle Name:
THERESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC, LAT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083911861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7300 REINHARDT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALESKA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30183-2981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-720-5821
Provider Business Mailing Address Fax Number:
770-720-5752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 REINHARDT CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALESKA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30183-2981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-720-5821
Provider Business Practice Location Address Fax Number:
770-720-5752
Provider Enumeration Date:
02/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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