Provider Demographics
NPI:1073892204
Name:KIMBERLIN, BETHANY KIYAH
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:KIYAH
Last Name:KIMBERLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8338 E VIA DE LA LUNA
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3257
Mailing Address - Country:US
Mailing Address - Phone:480-231-7562
Mailing Address - Fax:
Practice Address - Street 1:25615 N RANCH GATE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-2141
Practice Address - Country:US
Practice Address - Phone:480-221-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA72442355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ112477OtherOTHER