1164553335 NPI number — MRS. KIMBERLY DIANE LEVENHAGEN DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164553335 NPI number — MRS. KIMBERLY DIANE LEVENHAGEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEVENHAGEN
Provider First Name:
KIMBERLY
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEVENHAGEN
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
MOORE
Provider Other Name Prefix Text:
PROF.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1164553335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 WEBSTER PATH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63119-3941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-963-1171
Provider Business Mailing Address Fax Number:
314-968-8298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3437 CAROLINE ST
Provider Second Line Business Practice Location Address:
ROOM 1026
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-8548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1887 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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