Provider Demographics
NPI:1801884499
Name:MAZIK, KIMBERLY A (PT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:MAZIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1014 BUSINESS PARK DR STE A
Mailing Address - Street 2:PO BOX 5786
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-5233
Mailing Address - Country:US
Mailing Address - Phone:208-788-6312
Mailing Address - Fax:208-578-1053
Practice Address - Street 1:1014 BUSINESS PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-5233
Practice Address - Country:US
Practice Address - Phone:208-788-6312
Practice Address - Fax:208-578-1053
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-08
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1168225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1653364Medicare ID - Type UnspecifiedINDIVIDUAL