Provider Demographics
NPI:1114968906
Name:HEBERT, KIMBERLY MICHELLE (MPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:HEBERT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:3200 LOS ANGELES AVE.
Mailing Address - Street 2:#20
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065
Mailing Address - Country:US
Mailing Address - Phone:805-581-4266
Mailing Address - Fax:805-581-5049
Practice Address - Street 1:3200 LOS ANGELES AVE.
Practice Address - Street 2:#20
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065
Practice Address - Country:US
Practice Address - Phone:805-581-4266
Practice Address - Fax:805-581-5049
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT30034Medicare UPIN