Provider Demographics
NPI:1205287463
Name:BERRY, KATHRYN (PTA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BERRY
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 1:5540 W STONE BLUFF WAY
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-9274
Mailing Address - Country:US
Mailing Address - Phone:801-651-1229
Mailing Address - Fax:
Practice Address - Street 1:1430 E 4500 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84117-4208
Practice Address - Country:US
Practice Address - Phone:801-363-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5217245-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant