Healthcare Provider Details

I. General information

NPI: 1538680442
Provider Name (Legal Business Name): KIMBERLY A MARTIN MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 W TOUHY AVE STE 202
CHICAGO IL
60646-1248
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4291
  • Fax: 773-774-4527
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056011932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: