Basic Information
| Provider Information | |||||||||
| NPI: | 1194927434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | KYRA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LOTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2335 CHURCH ST | ||||||||
| Address2: | STE G | ||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707912700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256548208 | ||||||||
| FaxNumber: | 2256544642 | ||||||||
| Practice Location | |||||||||
| Address1: | 2335 CHURCH ST | ||||||||
| Address2: | STE G | ||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707912700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256548208 | ||||||||
| FaxNumber: | 2256544642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTT.Z11046 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4B790C943 | 01 | LA | MEDICARE | OTHER | 1025071 | 05 | LA | MEDICAID |