Provider Demographics
NPI:1720733694
Name:MINTZ, KATELYN C (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:C
Last Name:MINTZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:KATELYN
Other - Middle Name:C
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1132 RUTHERFORD RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-3927
Mailing Address - Country:US
Mailing Address - Phone:864-250-0005
Mailing Address - Fax:864-250-0028
Practice Address - Street 1:1132 RUTHERFORD RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-3927
Practice Address - Country:US
Practice Address - Phone:864-250-0005
Practice Address - Fax:864-250-0028
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH4910Medicaid