1649312687 NPI number — KATHLEEN M. ONEILL DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649312687 NPI number — KATHLEEN M. ONEILL DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ONEILL
Provider First Name:
KATHLEEN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'NEILL-MANRIQUE
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649312687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUBA CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86045-3398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-283-2659
Provider Business Mailing Address Fax Number:
928-283-2197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3008 EAST BIRCH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUBA CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86045-0600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-283-2659
Provider Business Practice Location Address Fax Number:
928-283-2197
Provider Enumeration Date:
02/13/2007

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: 225100000X , with the licence number:  004249 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 8058 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 524779 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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