Provider Demographics
NPI:1972501641
Name:MAES, KIMBERLY J (PT, CPED)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:MAES
Suffix:
Gender:F
Credentials:PT, CPED
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:QUEZON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, CPED
Mailing Address - Street 1:5813 SAWYER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9708
Mailing Address - Country:US
Mailing Address - Phone:719-289-4070
Mailing Address - Fax:
Practice Address - Street 1:5813 SAWYER RIDGE DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-9708
Practice Address - Country:US
Practice Address - Phone:719-289-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004104-A225100000X
CO9934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200277650-AMedicaid
P-06601Medicare UPIN