Provider Demographics
NPI:1124589965
Name:FORRESTER, KIMBERLY SUE (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:FORRESTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 OAK PARK CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1282
Mailing Address - Country:US
Mailing Address - Phone:765-969-7844
Mailing Address - Fax:
Practice Address - Street 1:1411 W COUNTY LINE RD STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-5250
Practice Address - Country:US
Practice Address - Phone:800-486-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003812A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant