Basic Information
| Provider Information | |||||||||
| NPI: | 1053565887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STRONG | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8112 ROUTE 12 | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BARNEVELD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158964330 | ||||||||
| FaxNumber: | 3158964331 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 WALTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132021885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154780380 | ||||||||
| FaxNumber: | 3154780388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2008 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 030842 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 00313539 | 05 | NY | MEDICAID | AA0172 | 01 | NY | MCR GRP FITNESS FORUM PT | OTHER | 01815443 | 05 | NY | MEDICAID | AA0171 | 01 | NY | MCR GRP # FITNESS FORUM PT | OTHER |