Provider Demographics
NPI:1689204612
Name:O'CONNOR, KAYTLYN ELLIDA (CMT, ROLFER)
Entity Type:Individual
Prefix:
First Name:KAYTLYN
Middle Name:ELLIDA
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:CMT, ROLFER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 BERKELEY WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1505
Mailing Address - Country:US
Mailing Address - Phone:510-717-8649
Mailing Address - Fax:
Practice Address - Street 1:5545 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1116
Practice Address - Country:US
Practice Address - Phone:510-717-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist