Provider Demographics
NPI:1699988725
Name:HENRY, KIMBERLY DIANE (COTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:HENRY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PEWTER CT
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-7614
Mailing Address - Country:US
Mailing Address - Phone:302-674-5637
Mailing Address - Fax:
Practice Address - Street 1:2502 SILVERSIDE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-3740
Practice Address - Country:US
Practice Address - Phone:302-478-3702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU2000005A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant