Provider Demographics
NPI:1700302452
Name:O'NEILL, KATHLEEN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:O'NEILL
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 1:1715 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2741
Mailing Address - Country:US
Mailing Address - Phone:781-248-0574
Mailing Address - Fax:
Practice Address - Street 1:3292 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-2309
Practice Address - Country:US
Practice Address - Phone:562-427-2225
Practice Address - Fax:562-427-2219
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA293524OtherSTATE LICENSE NUMBER