Provider Demographics
NPI:1336143833
Name:COSTELLO, KIMBERLY A (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:CONTRYMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3915 BRISTOL HWY
Mailing Address - Street 2:STE 301
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1403
Mailing Address - Country:US
Mailing Address - Phone:423-262-0020
Mailing Address - Fax:423-262-0057
Practice Address - Street 1:3915 BRISTOL HWY
Practice Address - Street 2:STE 301
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1403
Practice Address - Country:US
Practice Address - Phone:423-262-0020
Practice Address - Fax:423-262-0057
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT24222251N0400X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
3651038Medicare ID - Type Unspecified