Provider Demographics
NPI:1841547148
Name:WATESKA, KIMBERLY A (MPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:WATESKA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 E CANADA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:812-334-3010
Mailing Address - Fax:
Practice Address - Street 1:3211 E MOORES PIKE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7129
Practice Address - Country:US
Practice Address - Phone:812-334-7604
Practice Address - Fax:812-334-7705
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05008103A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist