Healthcare Provider Details

I. General information

NPI: 1326127960
Provider Name (Legal Business Name): KIM MARIE WALDEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 05/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 OAK RIDGE CHURCH RD
CORBIN KY
40701-5239
US

IV. Provider business mailing address

626 OAK RIDGE CHURCH RD
CORBIN KY
40701-5239
US

V. Phone/Fax

Practice location:
  • Phone: 606-515-1553
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT003448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: