Provider Demographics
NPI:1164120903
Name:BLACKWELL, KIMBERLY RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 TENNESSEE RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9725
Mailing Address - Country:US
Mailing Address - Phone:360-819-6751
Mailing Address - Fax:
Practice Address - Street 1:308 NE FIRST ST
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596
Practice Address - Country:US
Practice Address - Phone:360-762-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61395788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist