Provider Demographics
NPI:1780355495
Name:SIMMONS, KENDALL ERIN (OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:ERIN
Last Name:SIMMONS
Suffix:
Gender:F
Credentials: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 1:1025 BRANDING IRON RD
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1916
Mailing Address - Country:US
Mailing Address - Phone:920-655-3686
Mailing Address - Fax:
Practice Address - Street 1:1111 NORTH RD
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-9301
Practice Address - Country:US
Practice Address - Phone:608-847-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6455-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6455-26OtherWI DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES
418517OtherNATIONAL BOARD CERTIFICATION OF OCCUPATIONAL THERAPY