Provider Demographics
NPI:1124217724
Name:GATES, KATHLEEN NICOLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:GATES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 FOREST LAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4370
Mailing Address - Country:US
Mailing Address - Phone:740-375-8613
Mailing Address - Fax:
Practice Address - Street 1:195 FOREST LAWN BLVD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4370
Practice Address - Country:US
Practice Address - Phone:740-375-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 11908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist