Provider Demographics
NPI:1962046862
Name:BOLLINGER, KIMBERLY SUE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:BOLLINGER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17646 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:IL
Mailing Address - Zip Code:62037-2406
Mailing Address - Country:US
Mailing Address - Phone:618-593-9268
Mailing Address - Fax:
Practice Address - Street 1:2085 BLUESTONE DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6726
Practice Address - Country:US
Practice Address - Phone:636-896-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016035032224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant