Provider Demographics
NPI:1609875798
Name:RHODA, KIMBERLY KELLEHER (OT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KELLEHER
Last Name:RHODA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KELLEHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 TRINITY LN STE 111
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8112
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-661-8107
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-003079225X00000X
225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K15636Medicare ID - Type Unspecified