Provider Demographics
NPI:1164181830
Name:HANLEY, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HANLEY
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 1:159-70 HARLEM RIVER DR APT 5E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-1031
Mailing Address - Country:US
Mailing Address - Phone:918-405-6916
Mailing Address - Fax:
Practice Address - Street 1:55 MAPLE AVE STE 306
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4267
Practice Address - Country:US
Practice Address - Phone:516-639-4925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000Medicaid
NYCF32405AMedicaid