Provider Demographics
NPI:1962830786
Name:KIMBERLY M ROTHWELL
Entity Type:Organization
Organization Name:KIMBERLY M ROTHWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DANCE/MOVEMENT THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA BC-DMT, LCPC
Authorized Official - Phone:312-968-3154
Mailing Address - Street 1:838 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 N MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5176
Practice Address - Country:US
Practice Address - Phone:312-968-3154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
28374101YA0400X
IL180.007496101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty