Provider Demographics
NPI:1720661929
Name:TYE, KATHRYN MICHELLE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MICHELLE
Last Name:TYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MICHELLE
Other - Last Name:TYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:243 LA PALOMA APT C
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5125
Mailing Address - Country:US
Mailing Address - Phone:858-245-9784
Mailing Address - Fax:
Practice Address - Street 1:243 LA PALOMA APT C
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5125
Practice Address - Country:US
Practice Address - Phone:858-245-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist