Provider Demographics
NPI:1508189549
Name:VERREYDT, KIM L (LMT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:VERREYDT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:L
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:626 CORDOVA STREET
Mailing Address - Street 2:SUITE 105 ADVANCED BODY SOLUTIONS, INC.
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501
Mailing Address - Country:US
Mailing Address - Phone:907-277-5525
Mailing Address - Fax:907-277-5526
Practice Address - Street 1:626 CORDOVA ST STE 104
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3783
Practice Address - Country:US
Practice Address - Phone:907-277-5525
Practice Address - Fax:907-277-5526
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist