Provider Demographics
NPI:1659150910
Name:LYNCH, KALLIE KATHLEEN (DPT, PT)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:KATHLEEN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:WRIGHTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:92397-0210
Mailing Address - Country:US
Mailing Address - Phone:909-841-4339
Mailing Address - Fax:
Practice Address - Street 1:17270 BEAR VALLEY RD STE 105
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7751
Practice Address - Country:US
Practice Address - Phone:760-245-8828
Practice Address - Fax:855-891-9996
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist