Provider Demographics
NPI:1588070007
Name:OLSEN, KIMBERLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2032 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2604
Mailing Address - Country:US
Mailing Address - Phone:706-577-4857
Mailing Address - Fax:
Practice Address - Street 1:2032 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2604
Practice Address - Country:US
Practice Address - Phone:706-577-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist