Healthcare Provider Details

I. General information

NPI: 1649896226
Provider Name (Legal Business Name): KATE FOX COLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 RIVERSIDE DR PENTHOUSE 1, SECOND FLOOR
STUDIO CITY CA
91602-1093
US

IV. Provider business mailing address

12331 RIVERSIDE DR APT 7
VALLEY VILLAGE CA
91607-3635
US

V. Phone/Fax

Practice location:
  • Phone: 818-964-1144
  • Fax:
Mailing address:
  • Phone: 818-964-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number28395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: