Provider Demographics
NPI:1902919129
Name:OGLE, KIMBERLY
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:OGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:OGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:801 S BRIGGS ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-9591
Mailing Address - Country:US
Mailing Address - Phone:815-726-2463
Mailing Address - Fax:815-726-4431
Practice Address - Street 1:205 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-2854
Practice Address - Country:US
Practice Address - Phone:708-726-2468
Practice Address - Fax:708-726-4431
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70003620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12551Medicare ID - Type Unspecified