Provider Demographics
NPI:1609972132
Name:WALTERS, KIMBERLY JO (OTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2046
Mailing Address - Country:US
Mailing Address - Phone:317-875-9105
Mailing Address - Fax:317-875-8638
Practice Address - Street 1:8501 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2046
Practice Address - Country:US
Practice Address - Phone:317-875-9105
Practice Address - Fax:317-875-8638
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000516A225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200037030Medicaid
000000186321OtherANTHEM HEALTH PLAN
IN156524Medicare PIN
IN062110J4Medicare PIN