Healthcare Provider Details

I. General information

NPI: 1326356353
Provider Name (Legal Business Name): KATHLEEN ELIZABETH WHITE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1210
US

IV. Provider business mailing address

318 LA VETA DR. APT. 3
ALBUQUERQUE NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4628
  • Fax: 505-727-9515
Mailing address:
  • Phone: 505-319-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number5414
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: