Provider Demographics
NPI:1205130952
Name:MOORE, KIMBERLY JO (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 AUDUBON LN
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4324
Mailing Address - Country:US
Mailing Address - Phone:806-928-9893
Mailing Address - Fax:
Practice Address - Street 1:5072 W PLANO PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4483
Practice Address - Country:US
Practice Address - Phone:972-818-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist