Provider Demographics
NPI:1386293694
Name:MACVICAR, KATHLEEN CORLEY (DPT)
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:CORLEY
Last Name:MACVICAR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1758 FIXLINI ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3027
Mailing Address - Country:US
Mailing Address - Phone:831-917-5284
Mailing Address - Fax:
Practice Address - Street 1:211 TANK FARM RD STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7509
Practice Address - Country:US
Practice Address - Phone:805-439-3900
Practice Address - Fax:805-439-3901
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist