Provider Demographics
NPI:1558588368
Name:RAYNOVICH, KIMBERLEE MICHELE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEE
Middle Name:MICHELE
Last Name:RAYNOVICH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 TRIPLE TREE RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-7852
Mailing Address - Country:US
Mailing Address - Phone:406-587-0117
Mailing Address - Fax:
Practice Address - Street 1:612 E. MAIN ST,
Practice Address - Street 2:STE C EPICENTER THERAPY SERVICES
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-522-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2253PT225100000X
NJ40QA003572002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics