Provider Demographics
NPI:1568113207
Name:LINEBERGER, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LINEBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:TURBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29162-0209
Mailing Address - Country:US
Mailing Address - Phone:843-657-2290
Mailing Address - Fax:843-659-3204
Practice Address - Street 1:15 MAJOR DR
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3213
Practice Address - Country:US
Practice Address - Phone:803-435-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD235Z00000X
SC09143618235Z00000X
225100000X
SC225100000X, 225X00000X
SC103300163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC86-3905666Medicaid