Provider Demographics
NPI:1013103506
Name:BURGESS, KIMBERLY MARIE (DT/H)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DT/H
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 N ALLEN RD
Mailing Address - Street 2:UNIT 55
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3281
Mailing Address - Country:US
Mailing Address - Phone:309-838-5440
Mailing Address - Fax:
Practice Address - Street 1:6440 N ALLEN RD
Practice Address - Street 2:UNIT 55
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3281
Practice Address - Country:US
Practice Address - Phone:309-838-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB622-5138-3710222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist