Provider Demographics
NPI:1083854608
Name:BOURKE, KIMBERLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOURKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-2004
Mailing Address - Country:US
Mailing Address - Phone:516-935-2070
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist