Basic Information
| Provider Information | |||||||||
| NPI: | 1023295987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRIDELICH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 N SUMMIT AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624683480 | ||||||||
| FaxNumber: | 2624683481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5333 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XH1200X | 533 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | 234-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.