Provider Demographics
NPI:1407954001
Name:GUDEHUS, KIMBERLY R (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:GUDEHUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2823
Mailing Address - Country:US
Mailing Address - Phone:636-528-6080
Mailing Address - Fax:636-528-3973
Practice Address - Street 1:108 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2823
Practice Address - Country:US
Practice Address - Phone:636-528-6080
Practice Address - Fax:636-528-3973
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant