Provider Demographics
NPI:1861594210
Name:LINDBERG, KELLIE JO (OT)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:JO
Last Name:LINDBERG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N27W23960 PAUL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6327
Mailing Address - Country:US
Mailing Address - Phone:414-254-1565
Mailing Address - Fax:262-378-4394
Practice Address - Street 1:N27W23960 PAUL RD STE 4
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6327
Practice Address - Country:US
Practice Address - Phone:414-254-1565
Practice Address - Fax:262-378-4394
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1847-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40898800Medicaid
WI1760660377OtherNPI GROUP
WI40898800Medicaid
WI000180114Medicare PIN