Provider Demographics
NPI:1336486216
Name:GRACE, KIMBERLEY MICHEAL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:MICHEAL
Last Name:GRACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NATHAN DR
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:NH
Mailing Address - Zip Code:03285-6838
Mailing Address - Country:US
Mailing Address - Phone:603-391-5851
Mailing Address - Fax:
Practice Address - Street 1:30 NATHAN DR
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:NH
Practice Address - Zip Code:03285-6838
Practice Address - Country:US
Practice Address - Phone:603-391-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0178224Z00000X
NH0296225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant