Provider Demographics
NPI:1568096014
Name:STANFORD, KIMBERLY (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 E CROGAN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5069
Mailing Address - Country:US
Mailing Address - Phone:770-910-7227
Mailing Address - Fax:470-221-1514
Practice Address - Street 1:248 E CROGAN ST STE 5
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5069
Practice Address - Country:US
Practice Address - Phone:770-910-7227
Practice Address - Fax:470-221-1514
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014919225100000X
TX1296266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist