Provider Demographics
NPI:1518370964
Name:CARPENTER, KIMBERLY (MT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S CLOVER LN # 5
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-8768
Mailing Address - Country:US
Mailing Address - Phone:970-884-9779
Mailing Address - Fax:970-884-0847
Practice Address - Street 1:175 S CLOVER LN # 5
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-8768
Practice Address - Country:US
Practice Address - Phone:970-884-9779
Practice Address - Fax:970-884-0847
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT008192225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist