Provider Demographics
NPI:1962622084
Name:PORTER, KIMAWA KAY (PT, DPT, OMPT)
Entity type:Individual
Prefix:DR
First Name:KIMAWA
Middle Name:KAY
Last Name:PORTER
Suffix:
Gender:
Credentials:PT, DPT, OMPT
Other - Prefix:DR
Other - First Name:KIMAWA
Other - Middle Name:KAY
Other - Last Name:GUBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OMPT
Mailing Address - Street 1:4466 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3170
Mailing Address - Country:US
Mailing Address - Phone:810-285-8523
Mailing Address - Fax:810-820-9582
Practice Address - Street 1:4466 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3170
Practice Address - Country:US
Practice Address - Phone:810-285-8523
Practice Address - Fax:810-820-9582
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP45530026Medicare PIN
MIP45540026Medicare PIN