Provider Demographics
NPI:1316634306
Name:MCCOY, KATRINA (ATC, EMT)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 CHARLES WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-4023
Mailing Address - Country:US
Mailing Address - Phone:424-420-3399
Mailing Address - Fax:
Practice Address - Street 1:100 W GRAND AVE APT F
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-2368
Practice Address - Country:US
Practice Address - Phone:509-954-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty