Provider Demographics
NPI:1144293804
Name:BRESNAHAN, KATIE L (PT)
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:L
Last Name:BRESNAHAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:L
Other - Last Name:LOHSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:111 HEADWATERS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02645
Mailing Address - Country:US
Mailing Address - Phone:508-430-1717
Mailing Address - Fax:
Practice Address - Street 1:111 HEADWATERS DR
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-1028
Practice Address - Country:US
Practice Address - Phone:508-430-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA90878OtherFALLON
MAY68495OtherBLUE SHIELD
MA0708666Medicaid
MA494365OtherTUFTS
MAY68495OtherBLUE SHIELD