Provider Demographics
NPI:1124036165
Name:ECKER, KIMBERLY DAWN (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:ECKER
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-0095
Mailing Address - Country:US
Mailing Address - Phone:618-658-8144
Mailing Address - Fax:618-658-9146
Practice Address - Street 1:811 N 1ST STREET
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995
Practice Address - Country:US
Practice Address - Phone:618-658-8144
Practice Address - Fax:618-658-9146
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
048930OtherHEALTH ALLIANCE
59671OtherGHP
1179027OtherFIRST HEALTH
431187OtherHEALTHLINK
IL4423522OtherBLUE CROSS BLUE SHIELD
IL4423522OtherBLUE CROSS BLUE SHIELD
ILL95032Medicare ID - Type Unspecified