Healthcare Provider Details

I. General information

NPI: 1851375273
Provider Name (Legal Business Name): KATHERYN GRACE BOOBAR A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 WORLD CUP CIR
STRATTON MTN VT
05155-9252
US

IV. Provider business mailing address

PO BOX 218
PERU VT
05152-0218
US

V. Phone/Fax

Practice location:
  • Phone: 802-856-1136
  • Fax: 802-297-0020
Mailing address:
  • Phone: 570-204-0791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0000140
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: