Provider Demographics
NPI:1790748044
Name:STUMPHAUZER, KIMBERLY MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:STUMPHAUZER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 WINCKLES ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-366-5993
Mailing Address - Fax:440-366-5313
Practice Address - Street 1:137 WINCKLES ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035
Practice Address - Country:US
Practice Address - Phone:440-366-5993
Practice Address - Fax:440-366-5313
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT06051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH654140OtherAETNA
OH341490517042OtherCARESOURCE
OH2167462Medicaid
OH000000192879OtherANTHEM BLUE CROSS BLUE SH
OH000000192879OtherANTHEM BLUE CROSS BLUE SH