Healthcare Provider Details

I. General information

NPI: 1154479855
Provider Name (Legal Business Name): KIMBERLY J MIZE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY J MYERS PT

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 COLUMBINE RD
MISSOULA MT
59802-3332
US

IV. Provider business mailing address

9 CARRIAGE WAY
MISSOULA MT
59802-3330
US

V. Phone/Fax

Practice location:
  • Phone: 406-243-4684
  • Fax:
Mailing address:
  • Phone: 406-529-0951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1733
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: