Provider Demographics
NPI:1770716383
Name:VAN LOAN, KIMBERLY SUE (MS, OTR/L, CLT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:VAN LOAN
Suffix:
Gender:F
Credentials:MS, OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3064 COVINGTON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-7208
Mailing Address - Country:US
Mailing Address - Phone:605-787-2719
Mailing Address - Fax:605-718-4452
Practice Address - Street 1:3064 COVINGTON ST STE 104
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-7208
Practice Address - Country:US
Practice Address - Phone:605-787-2719
Practice Address - Fax:605-718-4452
Is Sole Proprietor?:No
Enumeration Date:2009-08-29
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0704225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1770716383Medicare NSC