Provider Demographics
NPI:1104385764
Name:CHU, KIMBERLY CLAIRE C
Entity Type:Individual
Prefix:
First Name:KIMBERLY CLAIRE
Middle Name:C
Last Name:CHU
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 1:601 BROADMOOR DR APT F
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3154
Mailing Address - Country:US
Mailing Address - Phone:917-794-7609
Mailing Address - Fax:
Practice Address - Street 1:2963 DODDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1736
Practice Address - Country:US
Practice Address - Phone:917-794-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013217A225100000X
MO2021033579261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist