Provider Demographics
NPI:1104800135
Name:COOMES, KATHRYN ELIZABETH (MPT)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:COOMES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:2400 W MALLARD CREEK CHURCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2324
Practice Address - Country:US
Practice Address - Phone:704-323-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005065A225100000X
NCP18957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730041OtherNSC #
IN200839620Medicaid
INP00100322Medicare UPIN
IN000000280275OtherBLUE CROSS BLUE SHIELD
IN255480SSMedicare PIN