Provider Demographics
NPI:1942786207
Name:BAYSTON, KIMBERLY ANN (MS/OTR)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:BAYSTON
Suffix:
Gender:F
Credentials:MS/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 BURCHELL AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:HIGHWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60040-1202
Mailing Address - Country:US
Mailing Address - Phone:815-549-3155
Mailing Address - Fax:
Practice Address - Street 1:601 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4315
Practice Address - Country:US
Practice Address - Phone:360-501-1904
Practice Address - Fax:360-501-1965
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60864496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist