Provider Demographics
NPI:1972742187
Name:KIMBRELL, ALISIA
Entity type:Individual
Prefix:
First Name:ALISIA
Middle Name:
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24370 MCCUTCHENVILLE RD
Mailing Address - Street 2:#17
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9499
Mailing Address - Country:US
Mailing Address - Phone:419-377-6126
Mailing Address - Fax:
Practice Address - Street 1:24370 MCCUTCHENVILLE RD
Practice Address - Street 2:#17
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-9499
Practice Address - Country:US
Practice Address - Phone:419-377-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17188225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist