Provider Demographics
NPI:1083147672
Name:LUND, KATHLEEN (PTA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LUND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 IRVINE AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4628
Mailing Address - Country:US
Mailing Address - Phone:508-851-0237
Mailing Address - Fax:
Practice Address - Street 1:2651 IRVINE AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4628
Practice Address - Country:US
Practice Address - Phone:508-851-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336312479Medicare UPIN
CA1043285117Medicare UPIN
1336312479Medicare UPIN