Provider Demographics
NPI:1124579842
Name:MINAHAN, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MINAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 W CANFIELD ST
Mailing Address - Street 2:205
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1317
Mailing Address - Country:US
Mailing Address - Phone:650-740-0318
Mailing Address - Fax:
Practice Address - Street 1:5101 JOHN C. LODGE
Practice Address - Street 2:101 MATTHAEI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-577-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010009412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer