Provider Demographics
NPI:1558338418
Name:MIMBERG, KERRY (MPT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:MIMBERG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 18TH ST NW STE 400
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-5209
Mailing Address - Country:US
Mailing Address - Phone:202-827-8317
Mailing Address - Fax:202-659-8724
Practice Address - Street 1:1015 18TH ST NW STE 400
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-5209
Practice Address - Country:US
Practice Address - Phone:202-827-8317
Practice Address - Fax:202-659-8724
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202775225100000X
DC870098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist