Provider Demographics
NPI:1962746917
Name:LAND, KIMBERLY S (OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:LAND
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 46TH PL
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4233
Mailing Address - Country:US
Mailing Address - Phone:312-545-5770
Mailing Address - Fax:
Practice Address - Street 1:535 E 46TH PL
Practice Address - Street 2:UNIT 3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4233
Practice Address - Country:US
Practice Address - Phone:312-545-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009720225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist