Provider Demographics
NPI:1356339642
Name:MATUSEVICH, KIMBERLY RENE (MPT, CLT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RENE
Last Name:MATUSEVICH
Suffix:
Gender:F
Credentials:MPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6600
Mailing Address - Country:US
Mailing Address - Phone:540-552-2294
Mailing Address - Fax:540-552-2296
Practice Address - Street 1:1901 S MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6600
Practice Address - Country:US
Practice Address - Phone:540-552-2294
Practice Address - Fax:540-552-2296
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00360698OtherMEDICARE RAILROAD
VA369793OtherMAMSI
VA7525558OtherAETNA
VA106123OtherANTHEM-BLACKSBURG OFFICE
VA106123OtherANTHEM-BLACKSBURG OFFICE
VAQ26673Medicare UPIN