Provider Demographics
NPI:1669029021
Name:BERGHOFF, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BERGHOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W 42ND ST STE 228
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3300
Mailing Address - Country:US
Mailing Address - Phone:316-698-7723
Mailing Address - Fax:
Practice Address - Street 1:1100 W 42ND ST STE 228
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-3300
Practice Address - Country:US
Practice Address - Phone:316-698-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15139882255R0406X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind