Provider Demographics
NPI:1508019787
Name:KAESBERG, DUSTY R (COTA)
Entity Type:Individual
Prefix:
First Name:DUSTY
Middle Name:R
Last Name:KAESBERG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11093 N PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4372
Mailing Address - Country:US
Mailing Address - Phone:618-910-1382
Mailing Address - Fax:
Practice Address - Street 1:11093 N PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4372
Practice Address - Country:US
Practice Address - Phone:618-910-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002965224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant