Provider Demographics
NPI:1407017999
Name:WILLMS COSGROVE, DORYNE JOELE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DORYNE
Middle Name:JOELE
Last Name:WILLMS COSGROVE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3309
Mailing Address - Country:US
Mailing Address - Phone:661-872-2121
Mailing Address - Fax:661-872-8371
Practice Address - Street 1:2211 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3309
Practice Address - Country:US
Practice Address - Phone:661-872-2121
Practice Address - Fax:661-872-8371
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist