Provider Demographics
NPI:1023261419
Name:DAHLBY, KIM CHANNING (PT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:CHANNING
Last Name:DAHLBY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7216 US HIGHWAY 301 N
Mailing Address - Street 2:STE 115
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-3462
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:4134 GULF OF MEXICO DR
Practice Address - Street 2:UNIT 209
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228-2612
Practice Address - Country:US
Practice Address - Phone:941-383-0120
Practice Address - Fax:941-383-0414
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAV289ZMedicare PIN
FLP00694471Medicare PIN