Provider Demographics
NPI:1922026491
Name:AFFLECK, KATHRYN M (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:AFFLECK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1206
Mailing Address - Country:US
Mailing Address - Phone:858-535-1075
Mailing Address - Fax:858-453-9810
Practice Address - Street 1:4520 EXECUTIVE DR
Practice Address - Street 2:STE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3023
Practice Address - Country:US
Practice Address - Phone:858-535-1894
Practice Address - Fax:858-535-1894
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT16034225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT16034COtherPPIN
W15730AMedicare ID - Type Unspecified