Provider Demographics
NPI:1205983418
Name:RICHARDSON, KIMBERLY DONN ROGERS (PT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DONN ROGERS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5224
Mailing Address - Country:US
Mailing Address - Phone:512-587-9491
Mailing Address - Fax:
Practice Address - Street 1:607 ROLLING GREEN DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5224
Practice Address - Country:US
Practice Address - Phone:512-587-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114155225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist