Provider Demographics
NPI:1548272925
Name:PHELAN, KATHRYN M (DOCTOR OF CHIROPRACT)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:M
Last Name:PHELAN
Suffix:
Gender:F
Credentials:DOCTOR OF CHIROPRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-1953
Mailing Address - Country:US
Mailing Address - Phone:805-473-8895
Mailing Address - Fax:
Practice Address - Street 1:575 S 4TH ST
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-1953
Practice Address - Country:US
Practice Address - Phone:805-473-8895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21777111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21777OtherLICENSE
U57881Medicare UPIN