Provider Demographics
NPI:1013491497
Name:CHANDLER, KATHLEEN LYNN (MT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W LINE STREET, SUITE J
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514
Mailing Address - Country:US
Mailing Address - Phone:760-937-0573
Mailing Address - Fax:
Practice Address - Street 1:214 W LINE STREET, SUITE J
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514
Practice Address - Country:US
Practice Address - Phone:760-937-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288818-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist