Provider Demographics
NPI:1700218724
Name:KLINE, KIM ELLEN (PTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ELLEN
Last Name:KLINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 PARTRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-4746
Mailing Address - Country:US
Mailing Address - Phone:608-362-8862
Mailing Address - Fax:
Practice Address - Street 1:470 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1014
Practice Address - Country:US
Practice Address - Phone:608-882-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2066-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant