Healthcare Provider Details

I. General information

NPI: 1235044629
Provider Name (Legal Business Name): KIMBERLY MECHAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7137 236TH AVE STE 101
SALEM WI
53168-8975
US

IV. Provider business mailing address

1265 30TH CT UNIT F
KENOSHA WI
53144-3035
US

V. Phone/Fax

Practice location:
  • Phone: 262-925-5060
  • Fax:
Mailing address:
  • Phone: 847-363-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number425319
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: