Provider Demographics
NPI:1487692232
Name:O'HARE, KIMBERLY (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:O'HARE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7511 LEMONT RD
Practice Address - Street 2:SUITE 204
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-4394
Practice Address - Country:US
Practice Address - Phone:630-985-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
IL070-010606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK31551Medicare PIN
COC805013Medicare PIN
CO811218Medicare PIN
IL216859202Medicare PIN
ILK31550Medicare PIN
IL202845181Medicare PIN