Provider Demographics
NPI:1306182415
Name:PRUTCH, KATRINA (PTA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:PRUTCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:MCCULLOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6367 S GRAPE CT
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-3532
Mailing Address - Country:US
Mailing Address - Phone:719-214-0922
Mailing Address - Fax:
Practice Address - Street 1:6367 S GRAPE CT
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-3532
Practice Address - Country:US
Practice Address - Phone:719-214-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012977225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant