Healthcare Provider Details

I. General information

NPI: 1497077077
Provider Name (Legal Business Name): KIMBERELY M MRAZ OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10257 W LINCOLN HWY
FRANKFORT IL
60423-1279
US

IV. Provider business mailing address

5816 E 9000N RD
MANTENO IL
60950-3506
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 815-468-3298
  • Fax: 815-468-3298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056001368
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: