Provider Demographics
NPI:1831383629
Name:KIMBROUGH, DEE DEE (COTA/L)
Entity type:Individual
Prefix:
First Name:DEE DEE
Middle Name:
Last Name:KIMBROUGH
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 1:460 ECHO LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1681 WILLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:CRESTHILL
Practice Address - State:IL
Practice Address - Zip Code:60403-2062
Practice Address - Country:US
Practice Address - Phone:815-744-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant