Healthcare Provider Details

I. General information

NPI: 1851732218
Provider Name (Legal Business Name): KIM MCKINNEY OT/PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S TREE GARDEN DR
ST AUGUSTINE FL
32086-5234
US

IV. Provider business mailing address

601 S TREE GARDEN DR
ST AUGUSTINE FL
32086-5234
US

V. Phone/Fax

Practice location:
  • Phone: 904-669-4285
  • Fax:
Mailing address:
  • Phone: 904-669-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 20437
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 9943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: