Provider Demographics
NPI:1982603114
Name:LEBRON, KIMBERLY B (RPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:LEBRON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:BARTLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2B LEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351
Mailing Address - Country:US
Mailing Address - Phone:860-376-2564
Mailing Address - Fax:860-376-4812
Practice Address - Street 1:2B LEE RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351-3042
Practice Address - Country:US
Practice Address - Phone:860-376-2564
Practice Address - Fax:860-376-4812
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004185741Medicaid
CT650000358Medicare PIN