Provider Demographics
NPI:1851535835
Name:BRACKETT, KIM (LMBT, NCTMB)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:LMBT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5113
Mailing Address - Country:US
Mailing Address - Phone:704-367-0561
Mailing Address - Fax:704-367-0561
Practice Address - Street 1:4601 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5113
Practice Address - Country:US
Practice Address - Phone:704-367-0561
Practice Address - Fax:704-367-0561
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4087225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist