Healthcare Provider Details

I. General information

NPI: 1366034373
Provider Name (Legal Business Name): KATHERINE CANTLEBARY ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 WEST TERMINAL DRIVE
SALT LAKE CITY UT
84122
US

IV. Provider business mailing address

4051 WEST TERMINAL DRIVE
SALT LAKE CITY UT
84122
US

V. Phone/Fax

Practice location:
  • Phone: 801-744-4008
  • Fax:
Mailing address:
  • Phone: 801-744-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number11864570-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: