MEDICARE: MRS. KIMBERLY SUE VAN LOAN MS, OTR/L, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	0704	SD

General Provider Information

NPI Number	:	1770716383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY SUE VAN LOAN MS, OTR/L, CLT

Provider Business Mailing Address
First Line	:	3064 COVINGTON ST STE 104
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57703-7208
Country	:	US
Telephone Number	:	605-787-2719
Fax Number	:	605-718-4452

Provider Business Practice Location Address
First Line	:	3064 COVINGTON ST STE 104
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57703-7208
Country	:	US
Telephone Number	:	605-787-2719
Fax Number	:	605-718-4452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2009
Last Update Date	:	09/15/2014

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