Provider Demographics
NPI:1568140564
Name:BOULOS, KIMBERLY ALEXIS (NJ LMT #18KT01515000)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALEXIS
Last Name:BOULOS
Suffix:
Gender:F
Credentials:NJ LMT #18KT01515000
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 ESSEX ST APT 4U
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-7514
Mailing Address - Country:US
Mailing Address - Phone:551-253-7256
Mailing Address - Fax:
Practice Address - Street 1:18 PARK VIEW AVE PH 2A
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-7389
Practice Address - Country:US
Practice Address - Phone:551-253-7256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No372600000XNursing Service Related ProvidersAdult Companion
No374J00000XNursing Service Related ProvidersDoula