MEDICARE: MARY KIMBERLIN

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	224Z00000X	Occupational Therapy Assistant	OTA03255	OH

General Provider Information

NPI Number	:	1528478666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KIMBERLIN

Provider Business Mailing Address
First Line	:	955 FOSTER AVE SE
Second Line	:	APT #2
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-3659
Country	:	US
Telephone Number	:	330-958-1781
Fax Number	:

Provider Business Practice Location Address
First Line	:	955 FOSTER AVE SE
Second Line	:	APT #2
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-3659
Country	:	US
Telephone Number	:	330-958-1781
Fax Number	:

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

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	04/29/2014

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Directions to “ MARY KIMBERLIN ” Practice Location

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