Provider Demographics
NPI:1902965189
Name:DAVIS, KATHLEEN KAY (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KAY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:KAY
Other - Last Name:BUNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1377 MOTOR PKWY
Mailing Address - Street 2:STE 307
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:
Practice Address - Street 1:4765 JACKSON RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103
Practice Address - Country:US
Practice Address - Phone:734-926-4710
Practice Address - Fax:734-926-4712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-09463225100000X
MI5501010838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI263541523OtherTAX ID
MI263541523OtherTAX ID