Provider Demographics
NPI:1659679892
Name:DEECK, KIMBERLY JEAN (MSPT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:DEECK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MIAMI AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3515
Mailing Address - Country:US
Mailing Address - Phone:267-467-1662
Mailing Address - Fax:
Practice Address - Street 1:801 WELLNESS WAY STE 100
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3783
Practice Address - Country:US
Practice Address - Phone:772-388-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-12
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013127L2251X0800X
FLPT302052251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA040128OtherPHYSICAL THERAPY MEDICARE PROVIDER NUMBER