Provider Demographics
NPI:1063055333
Name:PERRY, KIMBERLY DANIELLE (LMT, OTA, BT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:PERRY
Suffix:
Gender:F
Credentials:LMT, OTA, BT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:NESEMEIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:618 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4250
Mailing Address - Country:US
Mailing Address - Phone:757-221-1315
Mailing Address - Fax:
Practice Address - Street 1:618 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4250
Practice Address - Country:US
Practice Address - Phone:757-221-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010960225700000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist