Provider Demographics
NPI:1356679765
Name:BITTERLY, KATHRYN (LMT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BITTERLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 KILLDEER WAY
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12832-5245
Mailing Address - Country:US
Mailing Address - Phone:518-321-3707
Mailing Address - Fax:
Practice Address - Street 1:5 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-4067
Practice Address - Country:US
Practice Address - Phone:518-798-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018822-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist