Provider Demographics
NPI:1902019136
Name:GILLIS, KIMBERLY (OTR-L)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:GILLIS
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 1:3 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:HIGH FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12440-5012
Mailing Address - Country:US
Mailing Address - Phone:845-687-4181
Mailing Address - Fax:
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3950
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:800-451-9101
Practice Address - Fax:781-933-2828
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012992-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist