Provider Demographics
NPI:1265667851
Name:CHILDRESS, KIMBERLY SUE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:NORTONVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66060-5019
Mailing Address - Country:US
Mailing Address - Phone:417-499-1885
Mailing Address - Fax:954-212-2411
Practice Address - Street 1:2901 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:NORTONVILLE
Practice Address - State:KS
Practice Address - Zip Code:66060-5019
Practice Address - Country:US
Practice Address - Phone:417-499-1885
Practice Address - Fax:954-212-2411
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE470222Q00000X
MO2005032056222Q00000X
KS1702306222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist