Provider Demographics
NPI:1285983742
Name:CERDA, KIM MARIE WIPPERMAN (DPT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE WIPPERMAN
Last Name:CERDA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:WIPPERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:221 W DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1401
Practice Address - Country:US
Practice Address - Phone:574-256-9420
Practice Address - Fax:574-256-9465
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010935A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist