Provider Demographics
NPI:1679912356
Name:KALLEMBACH, DONALD EUGENE (OT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:EUGENE
Last Name:KALLEMBACH
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 W LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3529
Mailing Address - Country:US
Mailing Address - Phone:314-546-8840
Mailing Address - Fax:
Practice Address - Street 1:1224 W LAUREL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3529
Practice Address - Country:US
Practice Address - Phone:314-546-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004959225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist