Provider Demographics
NPI:1215579271
Name:KNOWLTON, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KNOWLTON
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 1:62603 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IN
Mailing Address - Zip Code:46554-9743
Mailing Address - Country:US
Mailing Address - Phone:574-656-8282
Mailing Address - Fax:
Practice Address - Street 1:62603 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IN
Practice Address - Zip Code:46554-9743
Practice Address - Country:US
Practice Address - Phone:574-655-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003819A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant