Provider Demographics
NPI:1255304465
Name:EBINGER, KIMBERLY ROSE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:EBINGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MANI
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:262-780-0717
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:STE 104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:262-780-0717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2713024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist