Provider Demographics
NPI:1770897803
Name:PERSONAL PT
Entity type:Organization
Organization Name:PERSONAL PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:CLARICE
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-598-6884
Mailing Address - Street 1:2174 SUNRISE CIR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2174 SUNRISE CIR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7409
Practice Address - Country:US
Practice Address - Phone:802-598-6884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33604225100000X
UT6039604-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty