Healthcare Provider Details

I. General information

NPI: 1720151285
Provider Name (Legal Business Name): KATHLEEN L SLADE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 S HIGHWAY 89
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 8467
JACKSON WY
83002-8467
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-5577
  • Fax: 307-733-5505
Mailing address:
  • Phone: 307-733-5577
  • Fax: 307-733-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-465
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: