MEDICARE: MRS. SHARON CHARLENE UTTERBACK LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	160004185	IL
2	225200000X	Physical Therapy Assistant	2004018741	MO

General Provider Information

NPI Number	:	1467713891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHARON CHARLENE UTTERBACK LPTA

Provider Business Mailing Address
First Line	:	224 LAS OLAS DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-3117
Country	:	US
Telephone Number	:	618-558-0830
Fax Number	:	618-332-7710

Provider Business Practice Location Address
First Line	:	2 ANNABLE CT
Second Line	:
City	:	CAHOKIA
State	:	IL
Zip	:	62206-2204
Country	:	US
Telephone Number	:	618-332-7710
Fax Number	:	618-332-7710

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2012
Last Update Date	:	06/01/2012

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Directions to “ MRS. SHARON CHARLENE UTTERBACK LPTA” Practice Location

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