Provider Demographics
NPI:1154538999
Name:TEDESCO, KIMBERLY ANNE (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1084
Mailing Address - Country:US
Mailing Address - Phone:608-882-9961
Mailing Address - Fax:
Practice Address - Street 1:470 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1014
Practice Address - Country:US
Practice Address - Phone:608-882-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10322-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist