Provider Demographics
NPI:1881795797
Name:SCHNEIDER, KIM (OTRL)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SCHNEIDER
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:5991 S 3500 W
Practice Address - Street 2:SUITE 300
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-6701
Practice Address - Country:US
Practice Address - Phone:801-985-2700
Practice Address - Fax:801-985-2707
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT338062-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1881795797Medicaid
UT870502207001Medicaid
UT870502207001Medicaid
P01275361Medicare PIN
UT000060372Medicare PIN