Basic Information
| Provider Information | |||||||||
| NPI: | 1346384567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLECK | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 845 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203220447 | ||||||||
| FaxNumber: | 9203221362 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203220447 | ||||||||
| FaxNumber: | 9203221362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1471-026 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 1471-028 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40727200 | 05 | WI | MEDICAID |