Provider Demographics
NPI:1083337943
Name:CRADLEBAUGH, KIMBERLY ANNE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:CRADLEBAUGH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16356 OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9091
Mailing Address - Country:US
Mailing Address - Phone:810-394-2064
Mailing Address - Fax:
Practice Address - Street 1:16356 OAK HILL DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9091
Practice Address - Country:US
Practice Address - Phone:810-394-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000502225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant