Provider Demographics
NPI:1962732834
Name:REAVES, KIMBERLY ANN (LMT, CMLDT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:REAVES
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7530 103RD ST STE 13
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-6786
Mailing Address - Country:US
Mailing Address - Phone:904-318-4957
Mailing Address - Fax:
Practice Address - Street 1:7530 103RD STREERT
Practice Address - Street 2:SUITE 13
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-318-4957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMM44961OtherESTABLISHMENT LICENSE
FLMA31726OtherPERSONAL LICENSE #