Provider Demographics
NPI:1477942191
Name:LEIS, KIMBERLY (OTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LEIS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24352 COUNTY HIGHWAY M
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:WI
Mailing Address - Zip Code:54670-6012
Mailing Address - Country:US
Mailing Address - Phone:608-797-6721
Mailing Address - Fax:
Practice Address - Street 1:307 ROYALL AVE
Practice Address - Street 2:
Practice Address - City:ELROY
Practice Address - State:WI
Practice Address - Zip Code:53929-1044
Practice Address - Country:US
Practice Address - Phone:608-462-8491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5084-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant