Provider Demographics
NPI:1174828214
Name:GAUDERMAN, KIMBERLY JEAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:GAUDERMAN
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 1:14215 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-2919
Mailing Address - Country:US
Mailing Address - Phone:952-491-3230
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD REHABILITATION SERVICES
Practice Address - Street 2:PARK NICOLLET METHODIST HOSPITAL
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist