Provider Demographics
NPI:1114977980
Name:GRACE, KATHLEEN (RPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11468 SORRENTO VALLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1347
Mailing Address - Country:US
Mailing Address - Phone:858-457-3545
Mailing Address - Fax:858-457-0976
Practice Address - Street 1:8929 UNIVERSITY CENTER LN
Practice Address - Street 2:200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1006
Practice Address - Country:US
Practice Address - Phone:858-457-3545
Practice Address - Fax:858-457-0976
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15003Medicare ID - Type Unspecified