Provider Demographics
NPI:1194927434
Name:MOSS, KYRA LEE (LOTR)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:LEE
Last Name:MOSS
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 CHURCH ST
Mailing Address - Street 2:STE G
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-654-8208
Mailing Address - Fax:225-654-4642
Practice Address - Street 1:2335 CHURCH ST
Practice Address - Street 2:STE G
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-8208
Practice Address - Fax:225-654-4642
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B790C943OtherMEDICARE
LA1025071Medicaid