Provider Demographics
NPI:1558634469
Name:TODD, KATHERINE FERNANDA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:FERNANDA
Last Name:TODD
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 1:611 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2420
Mailing Address - Country:US
Mailing Address - Phone:810-238-5789
Mailing Address - Fax:
Practice Address - Street 1:4052 LEGACY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4285
Practice Address - Country:US
Practice Address - Phone:517-397-0775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009596225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201009596OtherSTATE OF MICHIGAN