Provider Demographics
NPI:1144490236
Name:HENRY, KIMBERLY H (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:H
Last Name:HENRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:HEISEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:9077 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3405
Mailing Address - Country:US
Mailing Address - Phone:772-335-4770
Mailing Address - Fax:772-335-4133
Practice Address - Street 1:9077 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3405
Practice Address - Country:US
Practice Address - Phone:772-335-4770
Practice Address - Fax:772-335-4133
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFK996ZMedicare PIN