Healthcare Provider Details

I. General information

NPI: 1083659437
Provider Name (Legal Business Name): KIMBERLY JO DEVAULT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 COTTAGE GROVE RD
MADISON WI
53716-1392
US

IV. Provider business mailing address

4901 COTTAGE GROVE RD
MADISON WI
53716-1392
US

V. Phone/Fax

Practice location:
  • Phone: 608-221-1501
  • Fax: 608-223-3540
Mailing address:
  • Phone: 608-221-1501
  • Fax: 608-223-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3874-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: