Provider Demographics
NPI:1760494553
Name:GAVIN, KATHRYN ANNE (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:GAVIN
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 1:9725 BELMONT LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-3134
Mailing Address - Country:US
Mailing Address - Phone:912-704-6281
Mailing Address - Fax:
Practice Address - Street 1:1687 WOODLANE DR STE 201
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3047
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN531G0GAOtherBLUE CROSS BLUE SHIELD