Provider Demographics
NPI:1336551746
Name:DALE, KATIE BUFORD (,PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:BUFORD
Last Name:DALE
Suffix:
Gender:F
Credentials:,PT, DPT
Other - Prefix:MRS
Other - First Name:KATHARINE
Other - Middle Name:BUFORD
Other - Last Name:DALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:MS
Mailing Address - Zip Code:38928-0059
Mailing Address - Country:US
Mailing Address - Phone:662-897-4835
Mailing Address - Fax:
Practice Address - Street 1:702 HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5069
Practice Address - Country:US
Practice Address - Phone:662-455-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist