Basic Information
| Provider Information | |||||||||
| NPI: | 1386833390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRA | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 338 | ||||||||
| Address2: | |||||||||
| City: | NORTH FREEDOM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085224693 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 E. SECOND ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND CENTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086476321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 573-039 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.