Provider Demographics
NPI:1871592022
Name:KIMBALL, THERESA MULDOON (MPT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MULDOON
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 JANUS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3592
Mailing Address - Country:US
Mailing Address - Phone:541-747-1415
Mailing Address - Fax:541-747-1415
Practice Address - Street 1:1236 JANUS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3592
Practice Address - Country:US
Practice Address - Phone:541-747-1415
Practice Address - Fax:541-747-1415
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist