Provider Demographics
NPI:1982968996
Name:KIMBRELL, KATHERINE MICHELLE (OT/L)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELLE
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 J COBBER CT
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9560
Mailing Address - Country:US
Mailing Address - Phone:336-816-9309
Mailing Address - Fax:
Practice Address - Street 1:2040 HIGHWAY A1A STE 203
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3566
Practice Address - Country:US
Practice Address - Phone:321-773-8989
Practice Address - Fax:321-773-8990
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17979225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019203600Medicaid