Provider Demographics
NPI:1508162819
Name:EGAN, KIMBERLY A (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:EGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 COURTYARD PL
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3957
Mailing Address - Country:US
Mailing Address - Phone:937-885-0614
Mailing Address - Fax:
Practice Address - Street 1:1275 COURTYARD PL
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3957
Practice Address - Country:US
Practice Address - Phone:937-225-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT001909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413358Medicaid