Provider Demographics
NPI:1144350778
Name:CHILDRESS, CATHERINE PENN (DPT)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:PENN
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33201 HARBOUR VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5144
Mailing Address - Country:US
Mailing Address - Phone:904-810-2101
Mailing Address - Fax:904-810-2106
Practice Address - Street 1:1690 US HIGHWAY 1 S STE A
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6024
Practice Address - Country:US
Practice Address - Phone:904-810-2101
Practice Address - Fax:904-810-2106
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT228442251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22844OtherLICENSE