Provider Demographics
NPI:1912772807
Name:KIMBALL, TY KELBY (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:KELBY
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 WALNUT ACRES RD
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-9736
Mailing Address - Country:US
Mailing Address - Phone:360-751-3237
Mailing Address - Fax:
Practice Address - Street 1:2621 NE 134TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3036
Practice Address - Country:US
Practice Address - Phone:360-504-1022
Practice Address - Fax:360-859-1354
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist