Provider Demographics
NPI:1073748968
Name:VAN DEN ENDEN, KIMBERLY BROOKE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:VAN DEN ENDEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 BUENA FORTUNA CIR
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-8857
Mailing Address - Country:US
Mailing Address - Phone:209-765-3817
Mailing Address - Fax:
Practice Address - Street 1:309 BUENA FORTUNA CIR
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-8857
Practice Address - Country:US
Practice Address - Phone:209-765-3817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 17311235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist