Provider Demographics
NPI:1861619801
Name:LAIRD, KIM MARIE (ATP, PTA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:LAIRD
Suffix:
Gender:F
Credentials:ATP, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 OLD MOORINGSPORT RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2810
Mailing Address - Country:US
Mailing Address - Phone:318-347-3390
Mailing Address - Fax:
Practice Address - Street 1:401 E FRONT ST STE 224
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8250
Practice Address - Country:US
Practice Address - Phone:903-574-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2060503225200000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant