Provider Demographics
NPI:1659796969
Name:KERN, BETH MARIE
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:MARIE
Last Name:KERN
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 1:4302 W SHAMROCK LN APT 3G
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3140
Mailing Address - Country:US
Mailing Address - Phone:920-366-5629
Mailing Address - Fax:
Practice Address - Street 1:4302 W SHAMROCK LN APT 3G
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-3140
Practice Address - Country:US
Practice Address - Phone:920-366-5629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010229225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics