Provider Demographics
NPI:1144840018
Name:BASS, KIMBERLY A (LPTA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:BASS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 611
Mailing Address - Street 2:
Mailing Address - City:STANTONSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27883-0611
Mailing Address - Country:US
Mailing Address - Phone:252-238-3543
Mailing Address - Fax:
Practice Address - Street 1:8025 CREEDMOOR RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-4483
Practice Address - Country:US
Practice Address - Phone:919-846-1018
Practice Address - Fax:919-846-5958
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2625225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant