Provider Demographics
NPI:1033488507
Name:HAYWOOD, KIMBERLY WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WAYNE
Last Name:HAYWOOD
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 1:10 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-6642
Mailing Address - Country:US
Mailing Address - Phone:864-979-8406
Mailing Address - Fax:864-286-8289
Practice Address - Street 1:9 MAPLE TREE CT
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4070
Practice Address - Country:US
Practice Address - Phone:864-286-8288
Practice Address - Fax:864-286-8289
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2712225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant