Provider Demographics
NPI:1306021472
Name:ODONALD, KIMBERLEE J (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:J
Last Name:ODONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:J
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1330 W WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838
Mailing Address - Country:US
Mailing Address - Phone:616-754-7040
Mailing Address - Fax:616-754-7888
Practice Address - Street 1:1330 W WASHINGTON
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838
Practice Address - Country:US
Practice Address - Phone:616-754-7040
Practice Address - Fax:616-754-7888
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010081944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2679020Medicaid
30435OtherBCBS
236584Medicare PIN