Provider Demographics
NPI:1659369007
Name:DAVIS, KATHY J (PHD, ATC, CSCS)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-3803
Mailing Address - Country:US
Mailing Address - Phone:603-425-6335
Mailing Address - Fax:
Practice Address - Street 1:77 MASSACHUSETTS AVE
Practice Address - Street 2:W35-115
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-4908
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA112255A2300X
NH82255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2255A2300XOtherATHLETIC TRAINING SERVICE