Provider Demographics
NPI:1245579366
Name:DEAGON, KATHRYN
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:DEAGON
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 1:10442 CANTARA ST
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-4112
Mailing Address - Country:US
Mailing Address - Phone:818-331-7485
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHR STE 250
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4270
Practice Address - Country:US
Practice Address - Phone:562-256-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13577Medicaid