Provider Demographics
NPI:1053814707
Name:PINEDA, KIMBERLY (LOTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PINEDA
Suffix:
Gender:F
Credentials:LOTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:274 FEEDER ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-2203
Mailing Address - Country:US
Mailing Address - Phone:936-553-1501
Mailing Address - Fax:
Practice Address - Street 1:2420 PALUXY ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-3408
Practice Address - Country:US
Practice Address - Phone:936-553-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist