Provider Demographics
NPI:1366508467
Name:LEAIRD, KIMBERLY DAWN (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:LEAIRD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:LEAIRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:144 ADCOCK RD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-9236
Mailing Address - Country:US
Mailing Address - Phone:910-814-5885
Mailing Address - Fax:910-814-8558
Practice Address - Street 1:55 BAIN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9236
Practice Address - Country:US
Practice Address - Phone:910-814-5885
Practice Address - Fax:910-814-8558
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12012313OtherCAQH PROVIDER NUMBER
NC160MGOtherBCBS
NC12012313OtherCAQH PROVIDER NUMBER