Provider Demographics
NPI:1386833390
Name:BERRA, KYLE J (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:BERRA
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 338
Mailing Address - Street 2:
Mailing Address - City:NORTH FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:53951
Mailing Address - Country:US
Mailing Address - Phone:608-522-4693
Mailing Address - Fax:
Practice Address - Street 1:333 E. SECOND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI573-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer