Provider Demographics
NPI:1104902410
Name:BOOZELL, KIMBERLY SUE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:BOOZELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10853 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-9396
Mailing Address - Country:US
Mailing Address - Phone:740-334-1395
Mailing Address - Fax:740-892-3617
Practice Address - Street 1:32 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-1225
Practice Address - Country:US
Practice Address - Phone:740-967-0303
Practice Address - Fax:740-967-2332
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 05449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant