Provider Demographics
NPI:1316202211
Name:QUINN, KATHY GRANACK
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:GRANACK
Last Name:QUINN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:ELIZABETH
Other - Last Name:GRANACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2675 COURT DR
Mailing Address - Street 2:COMPLEAT KIDZ
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-824-4999
Mailing Address - Fax:704-824-3999
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:COMPLEAT KIDZ
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-4999
Practice Address - Fax:704-824-3999
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75312251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7213081Medicaid