Provider Demographics
NPI:1659360410
Name:LOVELACE, KIMBERLY A (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 CORTEZ RD W
Mailing Address - Street 2:STE 103
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3106
Mailing Address - Country:US
Mailing Address - Phone:941-739-7828
Mailing Address - Fax:941-739-7838
Practice Address - Street 1:3637 CORTEZ RD W
Practice Address - Street 2:STE 103
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3106
Practice Address - Country:US
Practice Address - Phone:941-739-7828
Practice Address - Fax:941-739-7838
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9042225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY909JOtherBCBS PROVDER
FL2288818OtherAETNA
FLDA6508OtherRR MCR PROVIDER
FLP00066542OtherRR MCR PROVIDER
FLE2367YMedicare UPIN
FL2288818OtherAETNA