Provider Demographics
NPI:1578128609
Name:EVOL, KIMBERLY BROOKE (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:EVOL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-2112
Mailing Address - Country:US
Mailing Address - Phone:812-798-6382
Mailing Address - Fax:
Practice Address - Street 1:946 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-2112
Practice Address - Country:US
Practice Address - Phone:812-798-6382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist