Provider Demographics
NPI:1396147278
Name:IKUTA, KATHLEEN (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:IKUTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S AMPHLETT BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2514
Mailing Address - Country:US
Mailing Address - Phone:650-638-9142
Mailing Address - Fax:650-638-9141
Practice Address - Street 1:1650 S AMPHLETT BLVD STE 108
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2514
Practice Address - Country:US
Practice Address - Phone:650-638-9142
Practice Address - Fax:650-638-9141
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417092251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics