Provider Demographics
NPI:1447825922
Name:RODRIGUEZ, KIMBERLY (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-6441
Mailing Address - Country:US
Mailing Address - Phone:618-698-1149
Mailing Address - Fax:
Practice Address - Street 1:58 MALLARD DR
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-6441
Practice Address - Country:US
Practice Address - Phone:618-698-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227015626225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist