Provider Demographics
NPI:1891992905
Name:TERRY, KATHLEEN NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:TERRY
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 1:198 CARLTON COURT
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175
Mailing Address - Country:US
Mailing Address - Phone:270-828-8719
Mailing Address - Fax:
Practice Address - Street 1:814 OLD EKRON RD
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1149
Practice Address - Country:US
Practice Address - Phone:270-422-2148
Practice Address - Fax:270-422-4791
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant