Provider Demographics
NPI:1659312460
Name:DANIELSEN, KIMO (PT)
Entity Type:Individual
Prefix:MR
First Name:KIMO
Middle Name:
Last Name:DANIELSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N HOBBS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-0828
Mailing Address - Country:US
Mailing Address - Phone:865-675-2527
Mailing Address - Fax:865-675-0998
Practice Address - Street 1:2771 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6381
Practice Address - Country:US
Practice Address - Phone:865-660-2402
Practice Address - Fax:865-675-0998
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3646041Medicaid
TN3646041Medicaid