Provider Demographics
NPI:1679554208
Name:MACE, KIMBERLY (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 TREMONT ST
Mailing Address - Street 2:BOX 120008
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5603
Mailing Address - Country:US
Mailing Address - Phone:617-636-5175
Mailing Address - Fax:617-636-5176
Practice Address - Street 1:260 TREMONT ST
Practice Address - Street 2:BOX 120008
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5603
Practice Address - Country:US
Practice Address - Phone:617-636-5175
Practice Address - Fax:617-636-5176
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69467Medicaid