Healthcare Provider Details

I. General information

NPI: 1265649081
Provider Name (Legal Business Name): KATHLEEN MARY PROSSER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 GELLERT BLVD SUITE 142
DALY CITY CA
94015-2621
US

IV. Provider business mailing address

486 MCCALL DR
BENICIA CA
94510-3925
US

V. Phone/Fax

Practice location:
  • Phone: 866-758-4700
  • Fax: 650-758-4711
Mailing address:
  • Phone: 707-297-6108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 8343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: