Provider Demographics
NPI:1376936138
Name:KIMBLE, SKYLAR TREVOR (LPTA)
Entity Type:Individual
Prefix:MR
First Name:SKYLAR
Middle Name:TREVOR
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 GOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-5054
Mailing Address - Country:US
Mailing Address - Phone:240-382-8313
Mailing Address - Fax:
Practice Address - Street 1:110 LAUCK DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22603-4282
Practice Address - Country:US
Practice Address - Phone:540-667-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603478225200000X
MDA3863225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant