Provider Demographics
NPI:1649941618
Name:VAN ELSBERG, KIMBERLY (COTA/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VAN ELSBERG
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 1:3004 MAMMOTH DR
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-8008
Mailing Address - Country:US
Mailing Address - Phone:218-686-2959
Mailing Address - Fax:
Practice Address - Street 1:2100 HARRISON AVE STE C
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6004
Practice Address - Country:US
Practice Address - Phone:406-690-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant