Provider Demographics
NPI:1851834386
Name:TRUMBULL-BODDY, KIMBERLY ANN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:TRUMBULL-BODDY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 BURTON ST SE
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4800
Mailing Address - Country:US
Mailing Address - Phone:616-333-2721
Mailing Address - Fax:616-719-1932
Practice Address - Street 1:2460 BURTON ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4801
Practice Address - Country:US
Practice Address - Phone:616-437-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist