Healthcare Provider Details

I. General information

NPI: 1467883017
Provider Name (Legal Business Name): KATLYN RUTH GROSSNICKLE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 112
PASADENA CA
91105-2552
US

IV. Provider business mailing address

200 E DEL MAR BLVD STE 112
PASADENA CA
91105-2552
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-2700
  • Fax: 626-564-2770
Mailing address:
  • Phone: 626-564-2700
  • Fax: 626-564-2770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: