Provider Demographics
NPI:1790477537
Name:STORDEUR, KIM (LMT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:STORDEUR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5248 COURSEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2302
Mailing Address - Country:US
Mailing Address - Phone:513-398-6300
Mailing Address - Fax:513-398-6363
Practice Address - Street 1:5248 COURSEVIEW DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2302
Practice Address - Country:US
Practice Address - Phone:513-398-6300
Practice Address - Fax:513-398-6363
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.021.39225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist