Provider Demographics
NPI:1821273863
Name:RILEY, KIMBERLY ANASTASIA (MPT,CLT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANASTASIA
Last Name:RILEY
Suffix:
Gender:F
Credentials:MPT,CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1751
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002896225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist