Provider Demographics
NPI:1811105604
Name:FREBORG, KIMBERLY ANN (OTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:FREBORG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:GEIGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5004 PINE PT
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-6012
Mailing Address - Country:US
Mailing Address - Phone:330-650-9813
Mailing Address - Fax:
Practice Address - Street 1:400 AUSTIN AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3554
Practice Address - Country:US
Practice Address - Phone:330-837-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-2411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
002413OtherAOTCB CERTIFICATION
OHOT-2411OtherSTATE LICENSE