Provider Demographics
NPI:1619421500
Name:GROTELUESCHEN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GROTELUESCHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W FAIRBORN LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-5602
Mailing Address - Country:US
Mailing Address - Phone:224-308-6555
Mailing Address - Fax:
Practice Address - Street 1:555 W FAIRBORN LN
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-5602
Practice Address - Country:US
Practice Address - Phone:224-308-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG634510959612255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program