Basic Information
| Provider Information | |||||||||
| NPI: | 1821328212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORRO | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | HANSON | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20410 CENTURY BLVD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208741186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015406140 | ||||||||
| FaxNumber: | 3015405190 | ||||||||
| Practice Location | |||||||||
| Address1: | 9501 OLD ANNAPOLIS RD | ||||||||
| Address2: | DORSEY HALL MEDICAL CENTER, SUITE 125 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210426314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109971063 | ||||||||
| FaxNumber: | 4109971408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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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 | 22921 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 182132821 | 05 | MD | MEDICAID | 182132821 | 01 | MD | MEDICARE | OTHER |