Healthcare Provider Details

I. General information

NPI: 1902179435
Provider Name (Legal Business Name): KIMBERLY VANDERKLOK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5644 TAVILLA CIR SUITE 104
NAPLES FL
34110-3362
US

IV. Provider business mailing address

5644 TAVILLA CIR SUITE 104
NAPLES FL
34110-3362
US

V. Phone/Fax

Practice location:
  • Phone: 239-514-5010
  • Fax: 239-514-5019
Mailing address:
  • Phone: 239-514-5010
  • Fax: 239-514-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 14944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: