Provider Demographics
NPI:1487021903
Name:REYES, KATHERINE MAE MIRANDA (PT)
Entity type:Individual
Prefix:
First Name:KATHERINE MAE
Middle Name:MIRANDA
Last Name:REYES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 BARNES DR APT 2107
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-5363
Mailing Address - Country:US
Mailing Address - Phone:916-335-0622
Mailing Address - Fax:
Practice Address - Street 1:1439 BARNES DR APT 2107
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5363
Practice Address - Country:US
Practice Address - Phone:916-335-0622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1217375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist