Provider Demographics
NPI:1548516917
Name:SPENCER, KIMBERLY ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:EMKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:802 ALLISON DR
Mailing Address - Street 2:
Mailing Address - City:TOLONO
Mailing Address - State:IL
Mailing Address - Zip Code:61880-9404
Mailing Address - Country:US
Mailing Address - Phone:217-621-7775
Mailing Address - Fax:
Practice Address - Street 1:802 ALLISON DR
Practice Address - Street 2:
Practice Address - City:TOLONO
Practice Address - State:IL
Practice Address - Zip Code:61880-9404
Practice Address - Country:US
Practice Address - Phone:217-621-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003596224Z00000X
IL056.015796225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant