Provider Demographics
NPI:1407350515
Name:WELLS, KIMBERLY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:WELLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:ME
Mailing Address - Zip Code:04002-7565
Mailing Address - Country:US
Mailing Address - Phone:203-430-3557
Mailing Address - Fax:
Practice Address - Street 1:850 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4901
Practice Address - Country:US
Practice Address - Phone:207-774-7878
Practice Address - Fax:207-879-6201
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT4399OtherMAINE STATE LICENSING BOARD