Provider Demographics
NPI:1588755318
Name:KROLL, KIMBERLY (OTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KROLL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N 19TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 3RD ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:MN
Practice Address - Zip Code:55718-9228
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6406076OtherNAHC MD INDIVIDUAL
MNHP45791OtherHEALTH PARTNERS
WI40902900Medicaid
MN530R8KROtherBCBS
MN088H0OOtherNAHC BC INDIVIDUAL
MNHP45791OtherHEALTH PARTNERS