Provider Demographics
NPI:1518162957
Name:MACOMB, KATHRYN ELIZABETH (MPT)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:MACOMB
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:LORELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:856 W CAGNEY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5297
Mailing Address - Country:US
Mailing Address - Phone:208-724-3870
Mailing Address - Fax:
Practice Address - Street 1:8660 W EMERALD ST STE 112
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4829
Practice Address - Country:US
Practice Address - Phone:208-321-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist