Provider Demographics
NPI:1043422256
Name:SHAFER, KATHLEEN NICOLE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:SHAFER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15943 W PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-5854
Mailing Address - Country:US
Mailing Address - Phone:928-232-9282
Mailing Address - Fax:
Practice Address - Street 1:15543 N REEMS RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9582
Practice Address - Country:US
Practice Address - Phone:623-975-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist