Provider Demographics
NPI:1720496250
Name:FITZSIMMONS, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:KASCHUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:49746 POTOMAC RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3465
Mailing Address - Country:US
Mailing Address - Phone:985-377-5469
Mailing Address - Fax:
Practice Address - Street 1:49746 POTOMAC RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-3465
Practice Address - Country:US
Practice Address - Phone:985-377-5469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010012892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer