Provider Demographics
NPI:1417914854
Name:DIVINCENZO, KIMBERLY A (ATC)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:A
Last Name:DIVINCENZO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1915
Mailing Address - Country:US
Mailing Address - Phone:716-838-5892
Mailing Address - Fax:
Practice Address - Street 1:2345 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2211
Practice Address - Country:US
Practice Address - Phone:860-633-5572
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000561-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer