Basic Information
Provider Information | |||||||||
NPI: | 1730278169 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOYD | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | LAVIGNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4780 N JOSEY LN | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | TX | ||||||||
PostalCode: | 750104615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724921334 | ||||||||
FaxNumber: | 9724925174 | ||||||||
Practice Location | |||||||||
Address1: | 4780 N JOSEY LN | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | TX | ||||||||
PostalCode: | 750104615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724921334 | ||||||||
FaxNumber: | 9724925174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 05/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1101749 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2251X0800X | 1101749 | TX | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | P00954322 | 01 | TX | RAILROAD MEDICARE | OTHER | 854T70 | 01 | TX | BC/BS TX - EFFECT. 02/01/2011 | OTHER | 8D5829 | 01 | TX | MEDICARE PART B - PRIOR TO 2/1/11 | OTHER | 8T3855 | 01 | TX | BCBS | OTHER | TXB121218 | 01 | TX | MEDICARE PART B - EFFECT 3/3/11 | OTHER | 4375780002 | 01 | TX | PALMETTO PROVIDER NUMBER | OTHER |