Provider Demographics
NPI:1417145319
Name:MATTHEWS, KIMBERLY SUE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 E 100 S
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-9520
Mailing Address - Country:US
Mailing Address - Phone:310-692-0670
Mailing Address - Fax:
Practice Address - Street 1:6330 N FIR RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4753
Practice Address - Country:US
Practice Address - Phone:574-977-8035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1609583225100000X
PAPT018989225100000X
IN05012697A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1417145319Medicaid