Provider Demographics
NPI:1063885259
Name:CHURCH, KATHERINE SARAH
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SARAH
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Mailing Address - Street 2:SUITE 410
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:407-905-9300
Mailing Address - Fax:407-905-9309
Practice Address - Street 1:5532 JFK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-588-3211
Practice Address - Fax:501-353-2599
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 30429225100000X
ARPT4458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229417721Medicaid