Provider Demographics
NPI:1194979922
Name:MCINNIS, KIMBERLY S (MSPT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1424
Mailing Address - Country:US
Mailing Address - Phone:914-837-6621
Mailing Address - Fax:
Practice Address - Street 1:698 YONKERS AVE
Practice Address - Street 2:SUITE 1J
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-2689
Practice Address - Country:US
Practice Address - Phone:914-969-3016
Practice Address - Fax:914-969-3722
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029805-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist