Basic Information
| Provider Information | |||||||||
| NPI: | 1760436901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORALES | ||||||||
| FirstName: | KARA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUMMOW | ||||||||
| OtherFirstName: | KARA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097970866 | ||||||||
| FaxNumber: | 3097970872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 03789 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070-014426 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03789 | 01 | IA | IOWA PT LICENSE NO. | OTHER | 326605115001 | 05 | IL | MEDICAID | 070-014426 | 01 | IL | ILLINOIS PT LICENSE NO. | OTHER |