Provider Demographics
NPI:1164525713
Name:MIELKE, KIMBERLY THERESE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:THERESE
Last Name:MIELKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640
Mailing Address - Country:US
Mailing Address - Phone:864-442-7482
Mailing Address - Fax:864-306-7977
Practice Address - Street 1:1807 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-442-7482
Practice Address - Fax:864-306-7977
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist