Provider Demographics
NPI:1083659437
Name:DEVAULT, KIMBERLY JO (PT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JO
Last Name:DEVAULT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1392
Mailing Address - Country:US
Mailing Address - Phone:608-221-1501
Mailing Address - Fax:608-223-3540
Practice Address - Street 1:4901 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-1392
Practice Address - Country:US
Practice Address - Phone:608-221-1501
Practice Address - Fax:608-223-3540
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3874-0242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083659437Medicaid