Basic Information
| Provider Information | |||||||||
| NPI: | 1578229886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATTERBERRY | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PTA, ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2518 HIDDEN VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | HOLTS SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650432524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149742235 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 DIAMOND RDG STE 800 | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651097906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737619360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2021 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2013005680 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225200000X | 2016037444 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.