Provider Demographics
NPI:1437130887
Name:BASS, KIMBERLY SCOTT (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SCOTT
Last Name:BASS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5314 W FRIENDLY AVE.
Mailing Address - Street 2:C,
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4351
Mailing Address - Country:US
Mailing Address - Phone:336-834-9740
Mailing Address - Fax:
Practice Address - Street 1:5314 W FRIENDLY AVE
Practice Address - Street 2:C
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4317
Practice Address - Country:US
Practice Address - Phone:336-834-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079RYOtherBLUE CROSS BLUE SHIELD
NC7211728Medicaid
NCE2479OtherMEDCOST
NCP00319081OtherMEDICARE RAILROAD
NC7211728Medicaid