Healthcare Provider Details

I. General information

NPI: 1609875798
Provider Name (Legal Business Name): KIMBERLY KELLEHER RHODA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY KELLEHER OT

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 04/20/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-661-8107
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-003079
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: