Healthcare Provider Details

I. General information

NPI: 1386992683
Provider Name (Legal Business Name): KIMBERLEY MARIE LOPEZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8335 AGORA PKWY STE 100
SELMA TX
78154-1383
US

IV. Provider business mailing address

12952 BANDERA RD SUITE 107
HELOTES TX
78023-4689
US

V. Phone/Fax

Practice location:
  • Phone: 210-658-8483
  • Fax: 210-658-0828
Mailing address:
  • Phone: 210-695-2682
  • Fax: 210-598-0432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1218553
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: