Provider Demographics
NPI:1598300147
Name:UTLEY, KIM (PTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:UTLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 PRIVATE ROAD 7952
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-5231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3011
Practice Address - Country:US
Practice Address - Phone:903-342-3987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant