Provider Demographics
NPI:1043434251
Name:KIVLIGHAN, KIMBERLY MARIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:KIVLIGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ST
Mailing Address - Street 1:1397 S CANFIELD NILES RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4084
Mailing Address - Country:US
Mailing Address - Phone:330-953-0129
Mailing Address - Fax:330-953-0650
Practice Address - Street 1:1397 S CANFIELD NILES RD
Practice Address - Street 2:UNIT 1
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4084
Practice Address - Country:US
Practice Address - Phone:330-953-0129
Practice Address - Fax:330-953-0650
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCSP2005110235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3032248Medicaid
OH3032248Medicaid