Provider Demographics
NPI:1730298860
Name:DEFAZIO, KATHERINE (PT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 TENDER VIOLET PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-6402
Mailing Address - Country:US
Mailing Address - Phone:936-718-2458
Mailing Address - Fax:
Practice Address - Street 1:1011 MEDICAL PLAZA DR
Practice Address - Street 2:#150
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3249
Practice Address - Country:US
Practice Address - Phone:281-367-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1036879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1036879OtherLICENSE #