Provider Demographics
NPI:1558300657
Name:HOLT, KIMBERLEY K (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:K
Last Name:HOLT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KIMBERLEY
Other - Middle Name:KEITH
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2149 ELECTRIC ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-774-9000
Mailing Address - Fax:540-774-6666
Practice Address - Street 1:2149 ELECTRIC ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-774-9000
Practice Address - Fax:540-774-6666
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010052033Medicaid
VA010052033Medicaid
Q02862Medicare UPIN
VA00V710R95Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER