Provider Demographics
NPI:1508141870
Name:BEAL, KIMBERLY CHRISTINA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CHRISTINA
Last Name:BEAL
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 1:10716 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:TX
Mailing Address - Zip Code:79758-4905
Mailing Address - Country:US
Mailing Address - Phone:432-770-8379
Mailing Address - Fax:
Practice Address - Street 1:10716 E BROWN ST
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:TX
Practice Address - Zip Code:79758-4905
Practice Address - Country:US
Practice Address - Phone:432-770-8379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2063918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676535Medicare PIN
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN