Provider Demographics
NPI:1437763059
Name:SAAVEDRA, KYRA J (PTA)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:J
Last Name:SAAVEDRA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MICHIGAN ST. SOCORRO HIGH SCHOOL
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801
Mailing Address - Country:US
Mailing Address - Phone:575-838-3112
Mailing Address - Fax:
Practice Address - Street 1:1200 MICHIGAN ST. SOCORRO HIGH SCHOOL
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-838-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM365343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM120985388Medicaid