Provider Demographics
NPI:1962711515
Name:REICHERT, KOTA BLAISE (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:KOTA
Middle Name:BLAISE
Last Name:REICHERT
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 KOFMAN CT.
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DRIVE
Practice Address - Street 2:H3124, M/C5284
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305
Practice Address - Country:US
Practice Address - Phone:650-498-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist