Provider Demographics
NPI:1255932729
Name:KIMBALL, MOLLY KALEEN (PTA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:KALEEN
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 MCINTOSH RD. SITE J-37
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527
Mailing Address - Country:US
Mailing Address - Phone:940-867-8004
Mailing Address - Fax:
Practice Address - Street 1:721 W ROBERTSON ST STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4900
Practice Address - Country:US
Practice Address - Phone:862-676-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30282208100000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation