Basic Information
| Provider Information | |||||||||
| NPI: | 1316202211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUINN | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | GRANACK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| OtherLastName: | GRANACK | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2675 COURT DR | ||||||||
| Address2: | COMPLEAT KIDZ | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048244999 | ||||||||
| FaxNumber: | 7048243999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 COURT DR | ||||||||
| Address2: | COMPLEAT KIDZ | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048244999 | ||||||||
| FaxNumber: | 7048243999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2012 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 7531 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7213081 | 05 | NC | MEDICAID |