Provider Demographics
NPI:1700119849
Name:DORTA, KATHRINE A (KATHRINE DORTA)
Entity type:Individual
Prefix:
First Name:KATHRINE
Middle Name:A
Last Name:DORTA
Suffix:
Gender:F
Credentials:KATHRINE DORTA
Other - Prefix:
Other - First Name:KASIE
Other - Middle Name:
Other - Last Name:DORTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:106 DAVIS MILL CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4635
Mailing Address - Country:US
Mailing Address - Phone:770-330-7975
Mailing Address - Fax:
Practice Address - Street 1:3444 CLUB DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2402
Practice Address - Country:US
Practice Address - Phone:770-330-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist