Healthcare Provider Details

I. General information

NPI: 1104339654
Provider Name (Legal Business Name): KATELYN MINIX PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATELYN HARRELL PT, DPT

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8491 FLETCHER PKWY
LA MESA CA
91942-3005
US

IV. Provider business mailing address

3959 RUFFIN RD STE J
SAN DIEGO CA
92123-1830
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-0137
  • Fax: 619-460-0139
Mailing address:
  • Phone: 858-279-5570
  • Fax: 858-279-5303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1298665
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: