Provider Demographics
NPI:1407368178
Name:KIM, MINDY CHERYL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:CHERYL
Last Name:KIM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:DIEP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:570-550-0168
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:3708 FORESTVIEW RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2391
Practice Address - Country:US
Practice Address - Phone:919-786-7434
Practice Address - Fax:919-786-7437
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP21262225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist