Provider Demographics
NPI:1063740124
Name:GOELLER, KATHLEEN POZDOL (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:POZDOL
Last Name:GOELLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6474 AMBROSIA DR APT 5102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6474 AMBROSIA DR APT 5102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3155
Practice Address - Country:US
Practice Address - Phone:619-296-0449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant