Provider Demographics
NPI:1922006303
Name:COCKRUM, KIMBERLY S (MSPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:COCKRUM
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:COCKRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:520 N CANYON ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2320
Mailing Address - Country:US
Mailing Address - Phone:605-642-7996
Mailing Address - Fax:605-642-5955
Practice Address - Street 1:520 N CANYON ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2320
Practice Address - Country:US
Practice Address - Phone:605-642-7996
Practice Address - Fax:605-642-5955
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4995254OtherWELLMARK BC/BS
SD5832932Medicaid
WY120143300Medicaid
SDQ24737Medicare UPIN
WY120143300Medicaid
SD5832932Medicaid