Provider Demographics
NPI:1316086150
Name:TYSON, KATHLEEN MONTGOMERY (PT)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MONTGOMERY
Last Name:TYSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18709 PLANNERS WAY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6421
Mailing Address - Country:US
Mailing Address - Phone:813-631-5073
Mailing Address - Fax:813-631-5040
Practice Address - Street 1:12220 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9201
Practice Address - Country:US
Practice Address - Phone:813-631-5073
Practice Address - Fax:813-631-5040
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist