Provider Demographics
NPI:1285967802
Name:RIVERS, KATIE ANN (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ANN
Last Name:RIVERS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 GALES AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3715
Mailing Address - Country:US
Mailing Address - Phone:334-332-6742
Mailing Address - Fax:336-293-8199
Practice Address - Street 1:617 GALES AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3715
Practice Address - Country:US
Practice Address - Phone:334-332-6742
Practice Address - Fax:336-293-8199
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC128812251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212896Medicaid