Provider Demographics
NPI:1053769695
Name:EDGERTON, KARA (DPT)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:EDGERTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 SAINT JOHNS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-3100
Mailing Address - Country:US
Mailing Address - Phone:817-310-8780
Mailing Address - Fax:817-310-8781
Practice Address - Street 1:2813 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6829
Practice Address - Country:US
Practice Address - Phone:817-310-8780
Practice Address - Fax:817-310-8781
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1274247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist