Provider Demographics
NPI:1821521444
Name:COLLINS, KIMBERLY RENE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RENE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RENE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:5726 SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2634 W JOHN BEERS RD
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-1213
Practice Address - Country:US
Practice Address - Phone:269-325-7167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001747225700000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist