Provider Demographics
NPI:1043338288
Name:CARSON, KIMBERLEY D (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:D
Last Name:CARSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-6913
Mailing Address - Fax:727-767-6757
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-6913
Practice Address - Fax:727-767-6757
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1064640225100000X
FLPT25044225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX107975803Medicaid