MEDICARE: KATELYN RENAE MINICK PT, DPT

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	225100000X	Physical Therapist	PT013623	GA
2	225100000X	Physical Therapist	9305	SC

General Provider Information

NPI Number	:	1750862686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN RENAE MINICK PT, DPT

Provider Business Mailing Address
First Line	:	6397 LEE HWY STE 300
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2564
Country	:	US
Telephone Number	:	442-323-8721
Fax Number	:	423-362-8684

Provider Business Practice Location Address
First Line	:	1017 FORDING ISLAND RD STE F-101
Second Line	:
City	:	BLUFFTON
State	:	SC
Zip	:	29910-4211
Country	:	US
Telephone Number	:	843-815-2563
Fax Number	:	843-815-2562

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

Provider Enumeration Date	:	08/28/2018
Last Update Date	:	09/12/2018

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