Provider Demographics
NPI:1679126973
Name:KIMBROUGH, MARY RICHEL (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RICHEL
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 E 37TH TER S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 OZARK TRAIL DR STE 1
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2164
Practice Address - Country:US
Practice Address - Phone:636-207-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019023929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist