Provider Demographics
NPI:1013563428
Name:HARROLD, KIMBERLY R (COTA/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:HARROLD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 W ADAMS DR
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-3113
Mailing Address - Country:US
Mailing Address - Phone:314-226-8811
Mailing Address - Fax:
Practice Address - Street 1:34 W ADAMS DR
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-3113
Practice Address - Country:US
Practice Address - Phone:314-226-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014123224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant