Provider Demographics
NPI:1669626123
Name:MARIO WIGGINS, KIMBERLY M (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:MARIO WIGGINS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:MARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:329 JONES RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3244
Mailing Address - Country:US
Mailing Address - Phone:607-624-8674
Mailing Address - Fax:
Practice Address - Street 1:1971 MARSHLAND RD
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732
Practice Address - Country:US
Practice Address - Phone:607-689-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012019-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist