Healthcare Provider Details

I. General information

NPI: 1215186747
Provider Name (Legal Business Name): KIMBERLY ANN DACEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29703 HOOVER RD STE A
WARREN MI
48093-8901
US

IV. Provider business mailing address

29888 DONNA LN
CHESTERFIELD MI
48047-5738
US

V. Phone/Fax

Practice location:
  • Phone: 586-582-0340
  • Fax: 586-582-9540
Mailing address:
  • Phone: 586-291-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001405A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: