Provider Demographics
NPI:1508092644
Name:CASTLE, KIMBERLY BODNAR (PT, PHD, PCS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BODNAR
Last Name:CASTLE
Suffix:
Gender:F
Credentials:PT, PHD, PCS
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:BODNAR
Other - Last Name:HARBST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1100 OLD DAWSON VILLAGE RD E STE 10
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-3807
Mailing Address - Country:US
Mailing Address - Phone:678-367-2382
Mailing Address - Fax:678-805-8452
Practice Address - Street 1:1100 OLD DAWSON VILLAGE RD E STE 10
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-3807
Practice Address - Country:US
Practice Address - Phone:608-526-9888
Practice Address - Fax:608-526-9865
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0112732251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40146300Medicaid
WI1508092644Medicaid