Provider Demographics
NPI:1851628051
Name:LONG, KIMBERLY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:LEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1844
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-1844
Mailing Address - Country:US
Mailing Address - Phone:864-482-0064
Mailing Address - Fax:864-482-0081
Practice Address - Street 1:12023 N RADIO STATION RD
Practice Address - Street 2:SUITE A
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1143
Practice Address - Country:US
Practice Address - Phone:864-985-0770
Practice Address - Fax:864-985-1770
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist