Provider Demographics
NPI:1629543301
Name:KLOTZ, AUDRA (PTA)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:KLOTZ
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 1:1963 GEORGIA CIR N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-1724
Mailing Address - Country:US
Mailing Address - Phone:727-373-9780
Mailing Address - Fax:
Practice Address - Street 1:300 LAKE AVE NE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-6605
Practice Address - Country:US
Practice Address - Phone:727-437-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21422225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant