Provider Demographics
NPI:1396861621
Name:MILLSAPS, KIMBERLY N (OTL)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:N
Last Name:MILLSAPS
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 NORTHFOREST DR
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-9102
Mailing Address - Country:US
Mailing Address - Phone:336-375-6011
Mailing Address - Fax:
Practice Address - Street 1:122 N ELM ST
Practice Address - Street 2:SUITE 400
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2878
Practice Address - Country:US
Practice Address - Phone:336-334-5601
Practice Address - Fax:336-334-5657
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC535225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13960OtherBLUE CROSS BLUE SHIELD
NC3403407Medicaid