Provider Demographics
NPI:1578739660
Name:FIDATI, KATHRYN B (PT, LMT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:B
Last Name:FIDATI
Suffix:
Gender:F
Credentials:PT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12180 WEXFORD CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1477
Mailing Address - Country:US
Mailing Address - Phone:404-904-3800
Mailing Address - Fax:
Practice Address - Street 1:12180 WEXFORD CLUB DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1477
Practice Address - Country:US
Practice Address - Phone:404-904-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16862225100000X
GAPT010510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149NMedicare PIN