Provider Demographics
NPI:1477722882
Name:TAGUE, KIMBERLY D (OTR)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:D
Last Name:TAGUE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 S 150 W
Mailing Address - Street 2:
Mailing Address - City:KOUTS
Mailing Address - State:IN
Mailing Address - Zip Code:46347-9789
Mailing Address - Country:US
Mailing Address - Phone:219-766-0781
Mailing Address - Fax:
Practice Address - Street 1:980 S 150 W
Practice Address - Street 2:
Practice Address - City:KOUTS
Practice Address - State:IN
Practice Address - Zip Code:46347-9789
Practice Address - Country:US
Practice Address - Phone:219-766-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003648A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist