Provider Demographics
NPI:1134438419
Name:KIRBY, KENTON DELL (PT)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:DELL
Last Name:KIRBY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:ROUNDUP
Mailing Address - State:MT
Mailing Address - Zip Code:59072-1816
Mailing Address - Country:US
Mailing Address - Phone:406-323-2301
Mailing Address - Fax:
Practice Address - Street 1:1202 3RD ST W
Practice Address - Street 2:
Practice Address - City:ROUNDUP
Practice Address - State:MT
Practice Address - Zip Code:59072-1816
Practice Address - Country:US
Practice Address - Phone:406-323-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2018-11-28
Deactivation Date:2011-12-21
Deactivation Code:
Reactivation Date:2018-11-28
Provider Licenses
StateLicense IDTaxonomies
MT1064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1064OtherLICENSE