Provider Demographics
NPI:1174524862
Name:ROSS, KIMBERLY M (OTR L,CHT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:OTR L,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 S WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1200
Mailing Address - Country:US
Mailing Address - Phone:801-587-7001
Mailing Address - Fax:801-581-4110
Practice Address - Street 1:590 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-7001
Practice Address - Fax:801-581-4110
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375157-4201225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT68950OtherPEHP
UT5417OtherDMBA
UTP00183940OtherRAILROAD MEDICARE
UT1108540001OtherCIGNA DMERC
UT6826064002OtherCIGNA
UT870388269BR1OtherEDUCATORS MUTUAL
UT99375157403001OtherBLUE CROSS BLUE SHIELD
UTP00183940OtherRAILROAD MEDICARE
UT68950OtherPEHP