Provider Demographics
NPI:1760447965
Name:MOORE, KATHRYN LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:LYNN
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-3611
Mailing Address - Fax:
Practice Address - Street 1:1470 E GASTON ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4431
Practice Address - Country:US
Practice Address - Phone:704-323-4065
Practice Address - Fax:704-323-3134
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4914225100000X
NCP21210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730037OtherNSC#
WIQ24046Medicare UPIN
WI0025Medicare ID - Type Unspecified
WI40439600Medicaid