Provider Demographics
NPI:1033393079
Name:GRIFFITH, KIMBERLY A (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:GRIFFITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1517
Mailing Address - Country:US
Mailing Address - Phone:260-438-3586
Mailing Address - Fax:260-432-7046
Practice Address - Street 1:6205 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1517
Practice Address - Country:US
Practice Address - Phone:260-438-3586
Practice Address - Fax:877-992-0273
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002279A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200681320AOtherFIRST STEPS
IN200681320AMedicaid