=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275966343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN FAZIO PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2013
-----------------------------------------------------
Last Update Date | 07/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11471 E LOOP 1604 N STE 101
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-428-7845
-----------------------------------------------------
Fax | 210-741-7699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11471 E LOOP 1604 N STE 101
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-428-7845
-----------------------------------------------------
Fax | 210-741-7699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 036747
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------