Provider Demographics
NPI:1558314518
Name:CLODFELTER, KATHLEEN MARY (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:CLODFELTER
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 1:25101 ARMAGOSA DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-1510
Mailing Address - Country:US
Mailing Address - Phone:949-249-1034
Mailing Address - Fax:
Practice Address - Street 1:200 W SANTA ANA BLVD
Practice Address - Street 2:#100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4134
Practice Address - Country:US
Practice Address - Phone:714-347-0300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19149225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics