Provider Demographics
NPI:1063032506
Name:O'LEARY, KIM DAWN (ATC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DAWN
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SAND CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8680
Mailing Address - Country:US
Mailing Address - Phone:925-595-5944
Mailing Address - Fax:
Practice Address - Street 1:4900 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8680
Practice Address - Country:US
Practice Address - Phone:925-779-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9001872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY900187OtherNATIONL ATHLETIC TRAINERS ASSOCIATION