Provider Demographics
NPI:1790466514
Name:SMITH, KIMBERLY DAWN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1589 R A WEST HWY
Mailing Address - Street 2:
Mailing Address - City:DELBARTON
Mailing Address - State:WV
Mailing Address - Zip Code:25670-6102
Mailing Address - Country:US
Mailing Address - Phone:304-784-3942
Mailing Address - Fax:
Practice Address - Street 1:46 FRIENDLY NEIGHBOR ROAD
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508
Practice Address - Country:US
Practice Address - Phone:304-855-7104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV923225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist