Provider Demographics
NPI:1649312687
Name:ONEILL, KATHLEEN M (DPT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:ONEILL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:O'NEILL-MANRIQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 3398
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-3398
Mailing Address - Country:US
Mailing Address - Phone:928-283-2659
Mailing Address - Fax:928-283-2197
Practice Address - Street 1:3008 EAST BIRCH AVENUE
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2659
Practice Address - Fax:928-283-2197
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004249225100000X
MA8058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ524779Medicaid