Provider Demographics
NPI:1891001103
Name:SMEAD, KIMBERLY MAE (MSPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MAE
Last Name:SMEAD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NEWFIELD AVE
Mailing Address - Street 2:APT 31
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2368
Mailing Address - Country:US
Mailing Address - Phone:203-962-5551
Mailing Address - Fax:
Practice Address - Street 1:107 NEWFIELD AVE
Practice Address - Street 2:APT 31
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2368
Practice Address - Country:US
Practice Address - Phone:203-962-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist