Basic Information
| Provider Information | |||||||||
| NPI: | 1962464941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEROY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | WHITE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1422 OLD WEISGARBER RD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584480 | ||||||||
| FaxNumber: | 8655584481 | ||||||||
| Practice Location | |||||||||
| Address1: | 1422 OLD WEISGARBER RD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584480 | ||||||||
| FaxNumber: | 8655584481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/04/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | OT12357 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | 5337 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 4393 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4305876 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 1525364 | 05 | TN | MEDICAID | 6096499 | 01 | TN | CIGNA | OTHER | 7259784 | 01 | AETNA | OTHER | P01005605 | 01 | TN | RAILROAD MEDICARE | OTHER |