Basic Information
Provider Information | |||||||||
NPI: | 1700853223 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEEDHAM | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROUTH | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 33900 HARPER AVE | ||||||||
Address2: | SUITE 104 | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480354258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864169100 | ||||||||
FaxNumber: | 5864169103 | ||||||||
Practice Location | |||||||||
Address1: | 9817 E US HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | IN | ||||||||
PostalCode: | 461237954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178607677 | ||||||||
FaxNumber: | 3178607668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 02/15/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05006846A | IN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 200274820 | 05 | IN |   | MEDICAID | 000000111999 | 01 | IN | ANTHEM ID | OTHER |