Provider Demographics
NPI:1023295987
Name:CRIDELICH, KIMBERLY L (OT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:CRIDELICH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1290 N SUMMIT AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-468-3480
Practice Address - Fax:262-468-3481
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5333225X00000X
AZ533225XH1200X
WI234-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
COOT0003849OtherSTATE LICENSE
WI60192OtherDEAN HEALTH INSURANCE