Provider Demographics
NPI: | 1497711014 |
---|---|
Name: | SPIVEY, KIMBERLY M (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | KIMBERLY |
Middle Name: | M |
Last Name: | SPIVEY |
Suffix: | |
Gender: | F |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | KIMBERLY |
Other - Middle Name: | M |
Other - Last Name: | MANN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PT |
Mailing Address - Street 1: | 6601 FARM LN |
Mailing Address - Street 2: | |
Mailing Address - City: | PINE BLUFF |
Mailing Address - State: | AR |
Mailing Address - Zip Code: | 71603-1313 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 870-879-9245 |
Mailing Address - Fax: | 870-541-0008 |
Practice Address - Street 1: | 2801 S OLIVE ST |
Practice Address - Street 2: | SUITE 9D |
Practice Address - City: | PINE BLUFF |
Practice Address - State: | AR |
Practice Address - Zip Code: | 71603-5439 |
Practice Address - Country: | US |
Practice Address - Phone: | 870-541-0003 |
Practice Address - Fax: | 870-541-0008 |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2006-04-22 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AR | PT 1318 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AR | 64-20055 | Other | UNITED HEALTHCARE |
AR | 5U308 | Other | BLUE CROSS |
AR | 5U308 | Medicare ID - Type Unspecified |