Provider Demographics
NPI:1902085566
Name:RUSSELL, KIMBERLY KD (OTR/L)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KD
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 N SPUALDING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647
Mailing Address - Country:US
Mailing Address - Phone:312-965-7633
Mailing Address - Fax:
Practice Address - Street 1:1812 N SPUALDING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647
Practice Address - Country:US
Practice Address - Phone:312-965-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008127225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist