Provider Demographics
NPI:1578667507
Name:SOARES, KIMBERLEE A (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:A
Last Name:SOARES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:A
Other - Last Name:SYLVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 SW INDUSTRIAL WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2529
Mailing Address - Fax:
Practice Address - Street 1:1303 NE CUSHING DR STE 150
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3891
Practice Address - Country:US
Practice Address - Phone:541-382-7875
Practice Address - Fax:541-382-2181
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007728225100000X
OR61984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500717984Medicaid
OR500717984Medicaid