Provider Demographics
NPI:1821615493
Name:BUSH, KIMBERLY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33875-6444
Mailing Address - Country:US
Mailing Address - Phone:954-696-7699
Mailing Address - Fax:
Practice Address - Street 1:208 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-1810
Practice Address - Country:US
Practice Address - Phone:954-696-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant