Provider Demographics
NPI:1942617840
Name:MOOS, KATHERINE LEE (MA, ATC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LEE
Last Name:MOOS
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LEE
Other - Last Name:HECKENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1533 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-2738
Mailing Address - Country:US
Mailing Address - Phone:336-631-1512
Mailing Address - Fax:
Practice Address - Street 1:1533 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-2738
Practice Address - Country:US
Practice Address - Phone:336-631-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-13
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670024332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer