Provider Demographics
NPI:1417074600
Name:KOOB, KATHY LYNN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:LYNN
Last Name:KOOB
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 BRONSON AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-1519
Mailing Address - Country:US
Mailing Address - Phone:269-685-1810
Mailing Address - Fax:
Practice Address - Street 1:1423 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5351
Practice Address - Country:US
Practice Address - Phone:269-323-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist