Provider Demographics
NPI:1497431209
Name:STAHL, KIMBERLY RENEE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:STAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3766 COUNTY ROAD 40A
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706
Mailing Address - Country:US
Mailing Address - Phone:260-466-6959
Mailing Address - Fax:
Practice Address - Street 1:1675 W SEVENTH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706
Practice Address - Country:US
Practice Address - Phone:260-627-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001794A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant