Provider Demographics
NPI:1710155239
Name:PETERSON, KIMBERLY D (BS OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 EXBURY GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6961
Mailing Address - Country:US
Mailing Address - Phone:704-256-4270
Mailing Address - Fax:
Practice Address - Street 1:3022 CHISHOLM CT
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7865
Practice Address - Country:US
Practice Address - Phone:704-843-2020
Practice Address - Fax:704-843-8384
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6775225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics