Healthcare Provider Details

I. General information

NPI: 1578984563
Provider Name (Legal Business Name): KIMBERLY K OTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 HAMACHER ST SUITE 205
WATERLOO IL
62298-1592
US

IV. Provider business mailing address

509 HAMACHER ST SUITE 205
WATERLOO IL
62298-1592
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4368
  • Fax: 888-371-4468
Mailing address:
  • Phone: 618-939-4368
  • Fax: 888-371-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000082
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: