Provider Demographics
NPI:1699966200
Name:HENRICHON, KIMBERLY (MEDOTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HENRICHON
Suffix:
Gender:F
Credentials:MEDOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WEST HATFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01088-9562
Mailing Address - Country:US
Mailing Address - Phone:413-586-8200
Mailing Address - Fax:413-582-1460
Practice Address - Street 1:4 WEST ST
Practice Address - Street 2:
Practice Address - City:WEST HATFIELD
Practice Address - State:MA
Practice Address - Zip Code:01088-9562
Practice Address - Country:US
Practice Address - Phone:413-586-8200
Practice Address - Fax:413-582-1460
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2466225X00000X
225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043527497OtherGREATWEST
MA043527497OtherCT CARE
MA64-04290OtherUHC
MA972730OtherNETWORK
MA043527497OtherCIGNA
MA103355100OtherDEPT OF LABOR
MA043527497OtherNORTH REGION
MA043527497OtherGIC
MA9715568Medicaid
MAPT0191Medicare PIN
MA64-04290OtherUHC
MA043527497OtherCT CARE
MA000349701Medicare PIN