Provider Demographics
NPI:1396972923
Name:WATTS, KIMBERLY GLORIA (OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GLORIA
Last Name:WATTS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 14TH ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-2621
Mailing Address - Country:US
Mailing Address - Phone:715-828-4425
Mailing Address - Fax:
Practice Address - Street 1:1011 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WI
Practice Address - Zip Code:54730
Practice Address - Country:US
Practice Address - Phone:715-962-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3813-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist