Provider Demographics
NPI:1376818260
Name:HARTLEY, KIMBERLY SHANAHAN (DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHANAHAN
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:SHANAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3851 COMMERCIAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4146
Mailing Address - Country:US
Mailing Address - Phone:843-314-5434
Mailing Address - Fax:888-510-9156
Practice Address - Street 1:3851 COMMERCIAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4146
Practice Address - Country:US
Practice Address - Phone:843-314-5434
Practice Address - Fax:888-510-9156
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH2737Medicaid