MEDICARE: MRS. PATRICIA M. VAN DEN KIEBOOM OTR

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	3263-026	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417934308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PATRICIA M. VAN DEN KIEBOOM OTR

Provider Business Mailing Address
First Line	:	6700 N. PORT WASHINGTON RD.
Second Line	:	C/O ST. FRANCIS CHILDREN'S CENTER
City	:	GLENDALE
State	:	WI
Zip	:	53217
Country	:	US
Telephone Number	:	414-351-8850
Fax Number	:	414-351-8846

Provider Business Practice Location Address
First Line	:	6700 N. PORT WASHINGTON RD.
Second Line	:	C/O ST. FRANCIS CHILDREN'S CENTER
City	:	GLENDALE
State	:	WI
Zip	:	53217
Country	:	US
Telephone Number	:	414-351-8850
Fax Number	:	414-351-8846

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

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	10/21/2010

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