Provider Demographics
NPI:1417934308
Name:VAN DEN KIEBOOM, PATRICIA M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:M
Last Name:VAN DEN KIEBOOM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 N. PORT WASHINGTON RD.
Mailing Address - Street 2:C/O ST. FRANCIS CHILDREN'S CENTER
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-351-8850
Mailing Address - Fax:414-351-8846
Practice Address - Street 1:6700 N. PORT WASHINGTON RD.
Practice Address - Street 2:C/O ST. FRANCIS CHILDREN'S CENTER
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-351-8850
Practice Address - Fax:414-351-8846
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3263-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40862700Medicaid