Healthcare Provider Details

I. General information

NPI: 1063651693
Provider Name (Legal Business Name): KIMBERELY DAWN ERTELT M.S. OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 9TH AVE NW
WATERTOWN SD
57201-1548
US

IV. Provider business mailing address

401 9TH AVE NW
WATERTOWN SD
57201-1548
US

V. Phone/Fax

Practice location:
  • Phone: 605-882-7000
  • Fax: 605-882-7636
Mailing address:
  • Phone: 605-882-7000
  • Fax: 605-882-7636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0619
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: