Provider Demographics
NPI:1073096939
Name:BOERTMAN, KATHLEEN M (OT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BOERTMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6842
Mailing Address - Fax:608-741-6953
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6842
Practice Address - Fax:608-741-6953
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-012093225X00000X
WI6315-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist