Provider Demographics
NPI:1083083729
Name:SOUTHERLAND, KATHYREN MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHYREN
Middle Name:MARIE
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:KATHYREN
Other - Middle Name:MARIE
Other - Last Name:PURSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3456 KLEMME RD
Mailing Address - Street 2:
Mailing Address - City:GERALD
Mailing Address - State:MO
Mailing Address - Zip Code:63037-1727
Mailing Address - Country:US
Mailing Address - Phone:573-219-6177
Mailing Address - Fax:
Practice Address - Street 1:1910 NURSING HOME RD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2844
Practice Address - Country:US
Practice Address - Phone:573-437-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007023630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant