Provider Demographics
NPI:1043325640
Name:MCDOUGAL, KIMBERLY D (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:301 REASONER LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-2201
Mailing Address - Country:US
Mailing Address - Phone:479-970-2175
Mailing Address - Fax:479-964-2126
Practice Address - Street 1:301 REASONER LN
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-2201
Practice Address - Country:US
Practice Address - Phone:479-970-2175
Practice Address - Fax:479-964-2126
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist