MEDICARE: KATHRINE A DORTA KATHRINE DORTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT003005	GA

General Provider Information

NPI Number	:	1700119849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRINE A DORTA KATHRINE DORTA

Provider Business Mailing Address
First Line	:	106 DAVIS MILL CT
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-4635
Country	:	US
Telephone Number	:	770-330-7975
Fax Number	:

Provider Business Practice Location Address
First Line	:	3444 CLUB DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-2402
Country	:	US
Telephone Number	:	770-330-7975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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