MEDICARE: DR. KYLIE WIDHELM LYNN WIDHELM OTD, OTR/L, BCPR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	1456	NE

General Provider Information

NPI Number	:	1033072236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLIE WIDHELM LYNN WIDHELM OTD, OTR/L, BCPR

Provider Business Mailing Address
First Line	:	10703 S 212TH ST
Second Line	:
City	:	GRETNA
State	:	NE
Zip	:	68028-3744
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2723 Q ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68107-3408
Country	:	US
Telephone Number	:	402-715-5464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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