Provider Demographics
NPI:1053535674
Name:BRINES, KIMBERLY (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRINES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10218 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3801
Mailing Address - Country:US
Mailing Address - Phone:708-349-6544
Mailing Address - Fax:
Practice Address - Street 1:16170 KINGSPORT RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5602
Practice Address - Country:US
Practice Address - Phone:708-349-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001562225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant