Provider Demographics
NPI:1760834352
Name:ANTONIDES, KAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:ANTONIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 HIGHWAY 16 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-3599
Mailing Address - Country:US
Mailing Address - Phone:830-796-3447
Mailing Address - Fax:830-796-3685
Practice Address - Street 1:8627 CINNAMON CREEK DR
Practice Address - Street 2:BLDG 402
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1480
Practice Address - Country:US
Practice Address - Phone:830-796-3447
Practice Address - Fax:830-796-3685
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3119382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist