Provider Demographics
NPI:1972670115
Name:WELLER, KIMBERLEY KAY (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:KAY
Last Name:WELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6553
Mailing Address - Fax:
Practice Address - Street 1:6896 SOUTH GREENVILLE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838
Practice Address - Country:US
Practice Address - Phone:616-754-2943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist