Provider Demographics
NPI:1730652355
Name:SMITH, KIMBERLY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:1682 CUP TREE RD
Mailing Address - Street 2:
Mailing Address - City:GRAVOIS MILLS
Mailing Address - State:MO
Mailing Address - Zip Code:65037-6930
Mailing Address - Country:US
Mailing Address - Phone:573-280-3321
Mailing Address - Fax:
Practice Address - Street 1:1101 W CLAY RD
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1177
Practice Address - Country:US
Practice Address - Phone:573-280-3321
Practice Address - Fax:573-539-3066
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006038459225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant