Provider Demographics
NPI:1528249372
Name:GEISNER-GROSS, KIMBERLY (OT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GEISNER-GROSS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:GEISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
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:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1160 DICKINSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-3122
Practice Address - Country:US
Practice Address - Phone:413-234-3198
Practice Address - Fax:413-234-2114
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002993225X00000X
MA8691225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist