Provider Demographics
NPI:1932503422
Name:PRICE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PRICE
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 1:463 PERKINS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOYIE SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83845-5104
Mailing Address - Country:US
Mailing Address - Phone:208-267-2975
Mailing Address - Fax:
Practice Address - Street 1:463 PERKINS LAKE RD
Practice Address - Street 2:
Practice Address - City:MOYIE SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83845-5104
Practice Address - Country:US
Practice Address - Phone:208-267-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG603225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist