Provider Demographics
NPI:1174735583
Name:LYONS, KIMBERLY (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LYONS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 GOODMAN AVE
Mailing Address - Street 2:APT# 4931
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9441 LYNDON B JOHNSON FWY
Practice Address - Street 2:#101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4545
Practice Address - Country:US
Practice Address - Phone:214-575-9820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2053710225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant