Provider Demographics
NPI:1417909763
Name:KNICKERBOCKER, CATHERINE L (PT)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:L
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 FERNS GLEN DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2303
Mailing Address - Country:US
Mailing Address - Phone:229-224-1282
Mailing Address - Fax:
Practice Address - Street 1:3147 FERNS GLEN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-2303
Practice Address - Country:US
Practice Address - Phone:229-224-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004553225100000X
FLPT4063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000688157HMedicaid
GA000688157EMedicaid