Provider Demographics
NPI:1487375507
Name:SMITH, KIMBERLY ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1046 DWANE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1644
Mailing Address - Country:US
Mailing Address - Phone:651-304-7008
Mailing Address - Fax:
Practice Address - Street 1:83 PLEASANT DRIVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033
Practice Address - Country:US
Practice Address - Phone:651-404-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105853225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist