Provider Demographics
NPI:1528461282
Name:GRIEST, KIMBERLY MICHELL (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELL
Last Name:GRIEST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-2278
Mailing Address - Country:US
Mailing Address - Phone:937-325-7671
Mailing Address - Fax:
Practice Address - Street 1:1500 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-1224
Practice Address - Country:US
Practice Address - Phone:937-505-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0003787225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant