Basic Information
| Provider Information | |||||||||
| NPI: | 1619357647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14043 PRATER CT | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322240867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573344402 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322074764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043465100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 04/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT30360 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | 30360 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 222Q00000X | PT30360 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.