Provider Demographics
NPI:1629172911
Name:GROVER, KIMBERLEY T (MPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:T
Last Name:GROVER
Suffix:
Gender:F
Credentials:MPT
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 135
Mailing Address - Street 2:
Mailing Address - City:SEELEY LAKE
Mailing Address - State:MT
Mailing Address - Zip Code:59868-0135
Mailing Address - Country:US
Mailing Address - Phone:406-677-7722
Mailing Address - Fax:406-677-7723
Practice Address - Street 1:3027 HWY 83
Practice Address - Street 2:LAZY PINE MALL
Practice Address - City:SEELEY LAKE
Practice Address - State:MT
Practice Address - Zip Code:59868
Practice Address - Country:US
Practice Address - Phone:406-677-7722
Practice Address - Fax:406-677-7723
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1478PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT60303OtherMEDICARE ADVANTAGE
MT000060303OtherBC/BS
MT3400904Medicaid
MTOTH000Medicare UPIN
MT3400904Medicaid