Provider Demographics
NPI:1255844916
Name:ENEBERG, KIM (PT)
Entity type:Individual
Prefix:MR
First Name:KIM
Middle Name:
Last Name:ENEBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 E FLETCHER AVE STE 133
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4709
Mailing Address - Country:US
Mailing Address - Phone:407-605-2321
Mailing Address - Fax:407-671-4155
Practice Address - Street 1:3500 E FLETCHER AVE STE 133
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4709
Practice Address - Country:US
Practice Address - Phone:407-605-2321
Practice Address - Fax:407-671-4155
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35351225100000X
FL35351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT60648721OtherSTATE LICENSE