Provider Demographics
NPI:1801121421
Name:TYSON, KATHERINE OLIVIA (DPT)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:OLIVIA
Last Name:TYSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:383 E 17TH ST APT C5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-5749
Mailing Address - Country:US
Mailing Address - Phone:347-295-2911
Mailing Address - Fax:347-295-2911
Practice Address - Street 1:383 E 17TH ST
Practice Address - Street 2:APT. C5
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5773
Practice Address - Country:US
Practice Address - Phone:347-295-2911
Practice Address - Fax:347-295-2911
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP71774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist