Provider Demographics
NPI:1093430316
Name:MCCORMICK, KIMBERLY LENEE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LENEE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16786
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0786
Mailing Address - Country:US
Mailing Address - Phone:214-493-3562
Mailing Address - Fax:
Practice Address - Street 1:5787 S HAMPTON RD STE 230B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-2255
Practice Address - Country:US
Practice Address - Phone:214-493-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2044774225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant