Provider Demographics
NPI:1063610921
Name:MIRER, KIMBERLY LYNN (OTRL)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:MIRER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:205 QUINNEHTUK RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2917
Mailing Address - Country:US
Mailing Address - Phone:413-567-2352
Mailing Address - Fax:
Practice Address - Street 1:61 COOPER ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2149
Practice Address - Country:US
Practice Address - Phone:413-786-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist