Provider Demographics
NPI:1023511631
Name:FORMBY, KIMBERLY (OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FORMBY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 DYERS BAY RD
Mailing Address - Street 2:
Mailing Address - City:STEUBEN
Mailing Address - State:ME
Mailing Address - Zip Code:04680-3118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 DYERS BAY RD
Practice Address - Street 2:
Practice Address - City:STEUBEN
Practice Address - State:ME
Practice Address - Zip Code:04680-3118
Practice Address - Country:US
Practice Address - Phone:207-619-1172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1802225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics