Provider Demographics
NPI:1467713891
Name:UTTERBACK, SHARON CHARLENE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:CHARLENE
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 LAS OLAS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3117
Mailing Address - Country:US
Mailing Address - Phone:618-558-0830
Mailing Address - Fax:618-332-7710
Practice Address - Street 1:2 ANNABLE CT
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2204
Practice Address - Country:US
Practice Address - Phone:618-332-7710
Practice Address - Fax:618-332-7710
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004185225200000X
MO2004018741225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant