Provider Demographics
NPI:1598831430
Name:SMITH, KIMBERLY C (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:C
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:19395 W CAPITOL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2736
Mailing Address - Country:US
Mailing Address - Phone:710-126-2923
Mailing Address - Fax:
Practice Address - Street 1:225 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:WI
Practice Address - Zip Code:54484-0156
Practice Address - Country:US
Practice Address - Phone:715-687-2214
Practice Address - Fax:715-687-4716
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9655-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40361300Medicaid