Provider Demographics
NPI:1427520113
Name:ROCHA, KIMBERLY ANN (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:ROCHA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12624 CRESTED BUTTE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7653
Mailing Address - Country:US
Mailing Address - Phone:801-419-7631
Mailing Address - Fax:
Practice Address - Street 1:411 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2502
Practice Address - Country:US
Practice Address - Phone:907-274-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9580749-4701225700000X
AK138811225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist