MEDICARE: MRS. STACY MARIE KIMPEL PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1153621	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BT1954	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1861460347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY MARIE KIMPEL PT

Provider Business Mailing Address
First Line	:	24015 ROCKYGATE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77373-7387
Country	:	US
Telephone Number	:	281-288-4515
Fax Number	:

Provider Business Practice Location Address
First Line	:	11811 FM 1960 RD W
Second Line	:	SUITE 102
City	:	HOUSTON
State	:	TX
Zip	:	77065-3827
Country	:	US
Telephone Number	:	281-469-8163
Fax Number	:	281-469-5559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/08/2007

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