Provider Demographics
NPI:1215043187
Name:BLAISDELL, KIMBERLY A (PT, MED)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:PT, MED
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:BLAISDELL
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT MED
Mailing Address - Street 1:45 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ESSEX JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3825
Mailing Address - Country:US
Mailing Address - Phone:802-878-7271
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:MCHV CAMPUS SHEP 2 PT DEPT
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-4731
Practice Address - Fax:802-847-3756
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist